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SYLLABUS 



A COURSE OF LECTURES 



DELIVERED IN THE 



ALABAMA MEDICAL COLLEGE, 

MOBILE. 
BY J. C. NOTT, 

PROF. OF SURGERY. 



PHILADELPHIA : 

J. B. LIPPINCOTT & CO. 
1861. 



v\ 



,\V°» 



Entered, according to act of Congress, in the year 1860, by 

J. B. LIPPINCOTT & CO., 

In the Clerk's Office of the District Court of the United States for the Eastern 

District of Pennsylvania. 



PREFACE. 



My time, between the organization of our College in the spring 
of 1859 and the commencement of the lectures in the following 
autumn, was spent in Europe, collecting our museum, and I en- 
tered upon my course without preparation. There being no text- 
book on surgery well adapted to the short course of instruction 
in the schools of the United States, (like those of Dorsey and 
Gibson in their day,) I felt the want of a more regular plan for 
my own convenience, and of some printed guide for the students 
to direct their reading. I therefore determined, as soon as the 
course was ended and leisure would permit, to write out and print 
a Syllabus. Unfortunately, however, I was attacked with a 
severe inflammation of the eyes, from which I am but just re- 
covering, and which has prevented me from carrying out my 
design in a satisfactory manner. I started for the mountains of 
Virginia early in June, with my eyes bandaged from the light, 
and hoping that I might still get well enough to read and write ; 
put in my trunk the "System of Surgery," by Professor Gross, 
which is the most complete, the best arranged, and, as a whole, 
best work on the subject in our language. I have followed very 
nearly the arrangement of Dr. Gross ; have indorsed the general 
principles he has laid down, and, as my amanuensis was not fa- 

(in) 



IV PREFACE. 

miliar with professional terms, etc., I have often had his very lan- 
guage copied. My object has not been to write a book, or to 
claim originality, but simply, under the circumstances, to make 
something which would be useful to the class. There will be 
found omissions, typographical errors, etc., in consequence of my 
inability to look over the manuscript and printed sheets while 
passing through the press. 

Notwithstanding all the defects above alluded to, I feel assured 
that this Syllabus will be a great assistance to the class, and will 
facilitate its members much in their course of study and prep- 
aration for the final examination. 

I hope before another year to publish a more complete edition. 

J. C. NOTT. 



SYLLABUS. 



The laws of disease, like those of health, are obscure, and to a 
great extent beyond the reach of our investigations. "We do not 
understand their true essence, and are often obliged to deal with 
effects. Hence we use conventional terms in our description of dis- 
eases, which are faulty in themselves, and whose definitions are un- 
settled and imperfect. Such for example are the terms Irritation, 
Congestion, and Inflammation. They are made to represent certain 
phenomena that occupy the attention of the surgeon every moment 
at the bedside, and require to be carefully studied. 

A normal state of the nervous system, and of the blood and its 
circulation through the organs of the body, are conditions indispens- 
able to health ; and whenever one or the other is deranged, diseased 
action is the consequence. 

IRRITATION. 

Irritation may be defined a disordered state of the nerves of the 
affected part, attended with more or less pain and functional disturb- 
ance, but not with inflammation, although it may lead, if not arrested, 
to that result. Its prominent symptom is nervous derangement; it 
bears the same relation to the nervous that inflammation does to the 
vascular system. The one consists essentially in disordered sensa- 
tion, the other in disordered circulation. 

Irritation may be limited in extent, local or widely diffused, mani- 
festing itself in many points, constituting general irritation. 

Irritation is direct or indirect, according as it results from local 
cause or sympathy. 

Examples of these different forms. 

An irritable state of the system greatly interferes with the repara- 
tive process, as healing of wounds, union of fractures, etc. 

Treatment. — Remove the cause ; correct secretions ; palliate and 
combat symptoms, etc. 

2 (5) 



SYLLABUS. 



CONGESTION. 



Difficulty of settling the boundaries between this and inflamma- 
tion, so nearly are they related. 

Definition.— Congestion is the accumulation of blood in a part, 
either from mechanical obstruction or some vital defect in the circu- 
lation interfering with the movement of this fluid. It is an accumu- 
lation of blood in a part, unaccompanied by the phenomena of true 
inflammation. 

Congestion, divided into Active and Passive. 

The first is characterized by increased action, heat, redness, and 
disturbance of function, and if allowed to progress, leads to deposits 
of serum and lymph. 

Passive congestion, on the other hand, is distinguished by the dark 
color of the part, dilated, sluggish state of the vessels, and its slow 
march. 

Sometimes improperly termed Arterial and Venous congestion ; 
but one set of vessels cannot be implicated without the other. 

Active congestion then is closely allied to inflammation, and when 
it results in morbid deposits, it becomes inflammation. 

Active congestion does not necessarily result in inflammation ; if 
the cause be removed it may cease. 

Examples. — Congestion of the conjunctiva from an irritant ; plunge 
the hand in cold water, etc. etc. 

Internal congestion similar to external. 

Distinction between active congestion and determination of blood 
to a part. 

Examples of latter. — Infant at the breast; menstruation; blush- 
ing ; congestion ; chills and fevers, and other forms of congestion. 

Passive Congestion. — In this the morbid action is more sluggish ; 
the vessels are distended, often varicose, tortuous, elongated and in- 
capable of contracting on their contents. The discoloration is dark, 
venous, or purple; circulation very languid, and often deposits of 
serum or lymph in the areolar tissue take place. 
Causes of Passive Congestion are — 

1st. Inflammation. 2d. Mechanical obstruction. 3d. Debility. 
4th. Dependent position. 
Examples of each. 



INFLAMMATION. 



INFLAMMATION: Its Importance. 

The present state of our knowledge does not enable us to give a 
satisfactory definition of this term ; the following, of Professor Gross, 
may be regarded as one of the best : — 

"Inflammation may be defined to be a perverted action of the 
capillary vessels of a part, attended with discoloration, pain, heat, 
swelling, and disordered function, with a tendency to effusion, depo- 
sits, or new products. In addition to these changes, there is also an 
altered condition of the blood and nervous fluid as an important 
element of the morbid process." 

Causes of Inflammation — endless. 
Predisposing — what ? Examples. 
Exciting — what ? Examples. 

Extension of Inflammation. 

Commences in a point. 

Extension by continuity. 

Extension by contiguity. 

Extension through veins and lymphatics. 

Extension through nervous agency — sympathy. 

Extension through the blood. 

Varieties of Inflammation. 

All the tissues susceptible of inflammation, except, perhaps, epi- 
dermis, hair, and nails. 

Susceptibility of a part to inflammation, as a general rule, in direct 
proportion to the amount of its vascular and nervous endowments ; 
the importance of its functions and nature of its exposure. 

Brain and heart most important exceptions. 

Acute and chronic inflammation — what ? 

Healthy and unhealthy inflammation — what ? 

Common and specific inflammation — what ? 

Latent inflammation — what ? 

Terminations or events of inflammation. 

In reality there are but two — one in. health, the other in death 
of the part. 
The first occurs by delitescence and resolution. 
The second occurs by ulceration and gangrene. 



8 SYLLABUS. 

Symptoms of acute inflammation are both local and constitutional. 
Most prominent local symptoms are redness, heat, swelling, and 
pain. 

1. Discoloration or redness ; its phenomena. 

Explanation. 

Yalue as a diagnostic sign. 

2. Pain — one of the most constant symptoms. 

Yaries in degree and kind. 

Sometimes remote from seat of disease. 

Most severe in the coverings of organs. 

Difference in the pain of inflammation and of spasm. 

Characters of neuralgia. 

Pain not always present in inflammation. 

Sudden disappearance often indicative of danger. 

How is pain produced ? 

Importance in pointing out the seat and danger of disease. 

Throbbing pain denotive of suppuration. 

3. Swelling — seldom though sometimes absent. 

Progress variable. 
Yaries in character. 
Beneficial or dangerous. 
Immediate cause of swelling. 

4. Heat — one of the most common effects of inflammation, and 

valuable guide. 
Degree of heat in inflamed tissues. 
Experiments of John Hunter. 

5. Functional disorder produced by inflammation. 

Increased sensibility. 
Increased irritability. 

Suspension of special functions, eye, ear, etc. 
Disorder of secretions. 
Absorption impeded or suspended. 
Constitutional symptoms. 
Not always present. 
Yascular system. 
Countenance. 
Respiratory organs. 
Digestive organs. 
Renal secretion. 
Muscles. 
Brain. 
Emaciation, etc. 



inflammation. 9 

Changes of the Blood in Inflammation. 

Influence on fibrin of inflammation. 
Influence on red globules. 
Bufify coat explained. 

Local Phenomena of Inflammation. 

If an irritant be applied to a sensitive living part, as for example 
a drop of alcohol, or point of a needle to the web of a frog's foot, 
the following phenomena which characterize the first steps of the in- 
flammatory process are seen to occur : — 

1st. There is a contraction of the capillary vessels, with partial 
arrest of the flow and oscillation of the blood corpuscles. If the 
irritation be slight, this effect is of but short duration, and the blood 
in a few seconds resumes its course. 

2d. If the irritation be more powerful, the vessels immediately 
dilate beyond their normal capacity, and a larger quantity of blood 
is admitted, the red globules being sent in with more velocity and in 
larger number by the increased action of the heart. The vessels 
become more and more expanded — extended to the utmost with the 
blood which stagnates — the function of the vessels and the function 
of the part are obliterated, and the coats of the vessels become 
thinned and softened. 

All this may be well studied in the conjunctiva of the eye when 
suddenly irritated. 

If the process runs high, blood is often extravasated through the 
coats or rupture of the vessels, and the parts are surrounded by great 
congestion of the vessels supplying them. The pulsation in the sur- 
rounding arteries is increased in force. There is also a copious 
exudation of lymph or plasma in the inflamed part, and an effusion of 
serum in the areolar tissue around. Next comes the formation of 
pus. 

In certain tissues, as the arachnoid membrane, the aponeuroses, 
cartilages, and nerves, we have no evidence, often, even in violent 
cases, of the exudation of lymph or formation of pus; and these 
should not then, as contended by Miller, Bennett, and others, be re- 
garded as essential phenomena of inflammation. Inflammation may 
and does exist without them. 

The nerves are doubtless deeply concerned in the development and 
progress of the inflammatory process, but in what manner we know 
not. Pain we know plays an important part in it, and the heart and 
other organs soon become implicated through the nervous system. 



10 syllabus. 

Treatment of Inflammation. 

1st. Remove exciting cause. 

2d. Promote resolution if possible. 

3d. Moderate and direct its action. 

Treatment both constitutional and local. 

The constitutional remedies are blood-letting, cathartics, emetics, 
depressants, mercurials, diaphoretics, diuretics, anodynes, and the 
antiphlogistic regimen. 

Importance of prompt treatment. 
Mode of action and manner of using. 
Blood-letting. 
Cathartics. 
Emetics. 
Depressants; nauseants; digitalis; aconite; veratrum vi- 

ride. 
Mercurials. 
Diaphoretics. 
Anodynes. 
Antiphlogistic regimen. 

Local remedies consist of rest, position, abstraction of blood, 
cold and warm applications, compression, counter-irritation, seda- 
tives, anodynes, etc. 

Mode of action and application of. 

Rest and position. 

Local bleeding. 

Cold and warm applications compared. 

Cold water. 

Warm water. 

Fomentations. 

Stuping. 

Poultices. 
Nitrate of silver. 
Iodine. 
Compression. 
Counter-irritants. 
Destructives. 
Blisters; setons; issues. 



INFLAMMATION. 11 

Chronic Inflammation. 

In what does it differ from acute inflammation ? 

Its results. 

Various forms. 

Treatment — general principles. 

Importance of attending to state of the system. 

Terminations and Results of Inflammation. 

Resolution — definition of. 
Delitescence — definition of. 
Examples of both. 

Deposition of Serum. 

A common attendant of inflammation. 

Cellular and serous tissues supply it most abundantly. 

Also poured out occasionally in large quantities from mucous 
membranes, as alimentary canal, etc. 

From skin, as in scalds, blisters, erysipelas, etc. 

(Ederna ; oedema of glottis ; peritoneal and plural cavities afford 
other examples. 

Serum effused is generally limpid ; when turbid, it is a mark of 
inflammation ; may contain blood, lymph, or pus. 

Dr. Gross contends that the effusion is always the result of in- 
flammation ; this opinion not general. 

Fibrinous Exudation. 

The terms fibrin, lymph, coagulable lymph, plasma, plastic matter, 
are synonymous. 

Inflammation rarely occurs without exudation of fibrin ; in many 
cases it is almost the only product of the morbid, action, as in croup, 
peritonitis. 

It is generally associated with serum; often with blood or pus, 
which denote a higher grade of inflammation than the mere effusion 
of serum. 

The capacity for furnishing fibrin in inflammation differs much in 
different times and organs. 

Most copious from serous membranes, cellular tissues, certain por- 
tions of mucous system, as the fauciar, laryngeal, intestinal, and 
uterine. 

Very little is effused from fibrous membranes, muscles, tendons, 
vessels, nerves, cartilages, or bones (except in fractures.) 



12 SYLLABUS. 

Sometimes fibrin is copiously effused in a few hours, at other times 
it commences and continues very slowly for an indefinite period. 
Appearance of fibrin or lymph when first poured out. 
Time and manner of its organization. 

Use of Plastic Matter. 

John Hunter was the first to describe its properties and uses. 

Manner of dressing wounds and healing for first intention. 

Parts entirely separated are sometimes made to unite. 

Taliacotius; noses; lips; ears. 

Du Hamel ingrafted the cock's spur into his comb. 

Hunter transplanted a human tooth in the same way. 

Use of plasma in suppression of hemorrhage, radical cure of her- 
nia, etc. 

Use in circumscribing morbid action as in abscesses, etc. , and in 
inclosing foreign bodies, balls, needles, etc. 

Use in obliterating serous cavities, hydrocele, etc. 

Injurious Effects of Plastic Matter. 

Although lymph has many important uses, it may on the other 
hand produce many injurious effects. 

Among the latter may be placed — 1st. Mechanical obstruction of 
natural outlets of the body. 2d. Change of structure by interstitial 
deposits. 3d. Abnormal adhesions. 4th. Induration and enlargement. 

Mechanical Obstruction. — Croup, in which the plastic matter is 
exuded on the external surface of mucous membrane of larynx and 
trachea ; strictures of urethra, rectum, etc., where the lymph is exuded 
beneath the membrane. 

Interstitial Deposit. — This occurs in almost all cases of inflamma- 
tion, in whatever situation or degree ; hepatization of lungs ; opacity 
of cornea ; enlargement of testicle ; lymphatic glands ; liver in hepa- 
titis, etc. etc. 

Abnormal Adhesions are results of inflammation and exudation 
of plastic matter; adhesions of pericardium; synovial membranes; 
peritoneum; pleura; vagina; muscles; tendons, etc. 

Induration and Enlargement. — Stiff, thickened joints ; enlarged 
testicle, liver, spleen, tonsils, lymphatic glands, etc. are examples. 

Treatment. — Constitutional remedies are mercury ; iodine ; atten- 
tion to secretions, digestive organs; tonics, etc. 

Local remedies, mercurial ointment or plaster; iodine; compres- 
sion ; cold douche ; frictions ; blisters, etc. 



INFLAMMATION. 13 

Suppuration. 

This is the process by which pus is formed, and is one of the com- 
mon and most important results of inflammation. 

It denotes a higher grade of inflammation than the mere deposi- 
tion of serum and lymph. Inflammation of certain kinds and in 
certain tissues occur, with copious exudation of serum, fibrin, and 
even blood, and without suppuration. 

It has been held by some, that pus may be formed without inflam- 
mation, but this opinion is generally repudiated at the present day. 

Pus may be formed without any solution of continuity of the 
affected part, as in the serous and mucous membranes; also in the 
cellular substance, lungs, brain, liver, and other viscera, where pus is 
often seen without ulceration. 

The tendency to formation of pus varies in different organs and 
tissues. 

Of the viscera, the liver, lungs, and brain ; of the tissues, the cel- 
lular, cutaneous, mucous, and serous, are most prone to suppuration. 

In the fibrous, cartilaginous, tendinous, and osseous structures, it 
takes place more imperfectly and with more difficulty. 

Some portions of the mucous system are more liable to suppura- 
tion than others. More common in the colon, in the vagina, urethra, 
in the nose, in the fauces, than in the stomach, uterus, bladder, mouth, 
or oesophagus ; in the bronchia than the larynx. 

So in the serous system, suppuration is most frequent in the pleura, 
tunica vaginalis, in the large joints. 

Blood-vessels rarely suppurate. Lymphatics are not much liable 
to it, but the lymphatic ganglions are, as in the groin, axilla, neck, etc. 

Nervous and muscular tissues seldom suppurate. 

The period at which suppuration may occur, after the establishment 
of inflammation, varies from twenty-four hours to three or four days 
on an average, according to tissue or organ affected, intensity, cause 
of the morbid action, and condition of the system. 

Mucous membranes, particularly when exposed to the air, sup- 
purate readily. Serous membranes, on the contrary, suppurate with 
difficulty, except when exposed to the air; in their natural, closed 
condition, they pour out serum, are naturally inclined to exude 
lymph, and to adhesive inflammation. 

Veins are much more liable to inflame and suppurate than arteries ; 
fortunate it is so, as arteries often require ligatures, and veins do not. 

In many of the viscera, brain, liver, etc., pus forms very rapidly 
sometimes. 

The more intense the inflammation, as a general rule, the more 



14 SYLLABUS. 

rapid the formation of pus. The period differs much in the grades 
of simple and in the specific forms of inflammation — as a common 
boil, chancre, scrofula, variola, etc. 

Exposure of an inflamed surface to the air greatly promotes sup- 
puration, and is a preventive of adhesion ; and this should be remem- 
bered in dressing wounds. 

Pus, when first effused, appears in distinct globules, dispersed 
through the affected tissues ; at length they are collected into a mass ; 
the tissues are broken down and disappear, and an abscess is the re- 
sult. 

The characters of pus cannot be properly studied without the use 
of the microscope. 

When genuine, or healthy, pus is of a white, yellowish tint, opaque, 
homogeneous, of a sweetish taste, without smell, and consistence of 
thin cream. It is heavier than water, in which it is partly dissolved ; 
emits a faint, mawkish odor on being heated to the natural tempera- 
ture of the body ; resists putrefaction with remarkable pertinacity, 
and is coagulated by heat, alcohol, and hydrochlorate of ammonia. 

By chemical analysis, pus is shown to contain most of the elements 
of blood. Microscopically examined, it is found to be composed of 
numerous small corpuscles suspended in a thin transparent fluid, 
called pus liquor. The globules vary from the 3 oVo *° Woo °^ an 
inch in diameter. Pus also contains shreds of fibrin and several 
varieties of corpuscles. 

Besides pure, healthy or laudable pus, there are several other 
varieties with different names. Sanious, serous, ichorous, or san- 
guinolent pus, is thin, almost transparent, of a yellowish, oily, or 
reddish color, and generally so acrid as to erode the parts with which 
it comes iu contact. This is the result of unhealthy inflammation, 
and is seen in caries of bones, irritable ulcers, cancers, etc. 

Fibrinous pus consists of common pus mingled with lymph ; it is 
whitish or ashy in color, and of semiliquid or lardaceous consistence ; 
most common in joints and splanchnic cavities; in metastatic ab- 
scesses and corpuscular inflammation. 

Scrofulous pus is seen in the lungs, cold abscesses, scrofulous dis- 
ease of joints, and in lymphatic ganglions. Usually separates into 
two parts, of which one is thick, straw colored, and inodorous; the 
other thin, ropy, and mixed with small, opaque, curdy flakes. Is 
often very offensive in odor. 

Muco-purulent pus is a term applied to certain discharges from 
mucus, epithelial scales, etc. ; from nose, eye, bronchial tubes, genito- 
urinary apparatus, etc. 



ABSCESSES. 15 

Certain kinds of pus, the result of specific inflammations, are con- 
tagious, as small-pox, gonorrhoea, chancre, etc. ; but we know nothing 
of the manner in which the poison is generated, or by which it acts. 

The question as to the production or formation of pus is one which 
has not yet been satisfactorily answered, and I will not occupy your 
time with speculations. The tissues of the part affected are in some 
way softened and broken down, the elements of the blood become 
changed, and pus results ; but how the change is produced we know 
not. 

Pus may be absorbed, perhaps in all its varieties, as is evinced by 
the disappearance of abscesses. 

ABSCESSES. 

An abscess is a circumscribed cavity of abnormal formation, con- 
taining pus. 

Purulent effusion is where pus is poured out into a natural cavity, 
as chest, joint, etc. 

Phlegmonous abscess is one which runs its course rapidly, and is 
accompanied by high inflammation. 

Symptoms of— are. 

Anatomy of. 

The pus accumulates in the cavity and is circumscribed by the 
gluing up of the cellular tissue around by adhesive inflammation. 
There is no distinct sac formed, as has been asserted. The pus at- 
tempts to reach the nearest surface through the action of the absorb- 
ents. The pressure of the pus aids the process much. 

Thus three processes are going on during the formation of an ab- 
scess : deposit of pus, effusion of lymph, and ulceration. 

Importance of the adhesive inflammation in preventing the diffusion 
of pus in surrounding structures and its escape into internal cavities. 

Contents of phlegmonous abscesses. 

Abscesses sometimes contain air. 

Phlegmonous abscesses may form in any part of body, but most 
common in areolar tissue ; occur in internal organs occasionally, as 
lungs, liver, brain, etc. 

Symptoms of phlegmonous abscess. 

Pointing of abscess. 

Constitutional symptoms. 

Diagnosis of abscess ; necessity of attending to following points : 
1st. History of case. 2d. Pointing. 3d. Fluctuation. 4th. (Edema. 
5th. Use of exploring needle. 



16 SYLLABUS. 

The affections most likely to be mistaken for abscess are encepha- 
loid, aneurism, and hernia. 
Prognosis. 
Treatment of phlegmonous abscess. 

Diffuse Abscess, or Purulent Infiltration, is where the collection 
of pus is not limited by adhesive inflammation, and is widely diffused 
among the tissues. Most common in persons of broken-down con- 
stitutions and intemperate habits, and in persons suffering under 
organic diseases; also in severe injuries, contusions, lacerations, 
compound fractures, dissection wounds, amputations, resections, etc. 
Very common in scrofulous subjects. 

Occur in conjunction with erysipelas, pyemia, or phlebitis. 

Symptoms of purulent infiltration — local and general. 

Prognosis very unfavorable. 

Indications of treatment are, to evacuate the matter and support 
the system. 

Scrofulous Abscess — often called chronic or cold abscess ; strumous 
or tubercular. 

Never met except in a strumous or scrofulous constitution ; prog- 
ress always slow, requiring weeks or months. Is not accompanied 
by evident symptoms of inflammation, there being neither heat nor 
redness ; there is even a deficiency of circulation ; pain also is com- 
monly wanting; the general strength and health gradually decline. 
Most common in lungs, lymphatic ganglia, and movable joints. 

The strumous abscess is nearly always furnished with a cyst, tech- 
nically called the pyogenic membrane, which characterize it and 
separates it from surrounding parts ; it is a result of adhesive inflam- 
mation ; its thickness varies from the eighth of a line to the eighth of 
an inch. Often becomes very dense ; adheres firmly to surrounding 
tissues. 

These abscesses are sometimes very large, as in psoas abscess, 
reaching a gallon. 

Treatment differs essentially from the phlegmonous. 

When strumous abscesses are situated externally, as in the mam- 
mary or lymphatic glands, subcutaneous cellular tissue, etc., they 
should be evacuated promptly as a general rule. 

After evacuation, the best local applications are stimulating poul- 
tices ; tincture iodine internally ; injections of dilute tincture of iron 
or solution of iodine ; soap liniment, etc. 

In deep-seated, large abscess, as psoas and others, we should be 



ABSCESSES. It 

very cautious in opening them. Many refuse to open them at all ; 
and when opened it should be done by a valvular opening — with a 
trocar. 

Multiple Abscess, or Pyemia. 

Pyemia signifies an alteration of the blood by pus, giving rise to 
what is termed purulent infection. 

Follows severe injuries, as those of the head, compound fractures 
and dislocations, lacerated, contused, and gunshot wounds. Not un- 
common after labor in females. In erysipelas, carbuncle, small-pox, 
scarlatina, and typhoid fever; in injuries of veins. Most common in 
bad constitutions, in the intemperate, and in hospitals and bad air. 

The immediate causes of pyemia are not determined. 

It is supposed by some that pus is absorbed and transferred in 
large quantity from one part of the system to another ; while others 
contend that pus globules are too large to be absorbed. 

The most rational theory, perhaps, is that advocated by Professor 
Bennett, of Edinburgh, as well as others, which supposes that a pecu- 
liar poison is developed in certain deposits of pus, which enters the 
circulation, contaminates the blood and solids, and produces the 
train of symptoms that characterize pyemia. According to this 
hypothesis, the corpuscles, as such, do not enter the circulation. 

This poisonous matter seems to have the effect of inflaming the 
capillaries and larger blood-vessels, particularly veins, in which are 
soon formed deposits of fibrin and pus ; and also of developing puru- 
lent collections in various distant parts of the system. The veins 
are often completely blocked up by coagula. 

The following example will illustrate the nature and progress of 
this condition : — 

A patient has had a limb amputated or injured otherwise ; after a 
few days the surgeon finds the wound not doing well; the patient 
complains ; the inflammation looks unhealthy ; manifests no disposi- 
tion to heal ; the discharge, instead of healthy pus, is a thin, bloody, 
ichorous fluid ; the patient is restless, looks pale, anxious, and 
alarmed; pulse irritable and frequent; cheeks flushed; secretions 
deranged. These symptoms may not last more than twenty-four 
hours, when severe rigors set in, which within an hour or two are 
followed by high febrile reaction, colliquative sweats, etc. The rigors 
return frequently at short intervals, and- at other times simulate in- 
termittent fever. 

The conjunctiva and skin become jaundiced ; the features are 
shrunken; eyes sunk in the sockets; pulse very rapid and feeble; 



18 SYLLABUS. 

respiration labored ; tongue dry and clammy ; thirst urgent; somno- 
lence; stomach irritable; bowels irregular, loose or constipated; 
urine scanty and high colored; coldness of extremities; delirium; 
severe pains in muscles and joints; often pains in internal organs, 
and cough, indicative of implication of lungs; red blotches appear 
on the joints, indicative of approaching suppuration. Similar marks 
occur in the course of veins and in other parts ; great emaciation . 
The symptoms go on steadily aggravating till death, the duration 
varying from three to ten or twelve days. 

On dissection, numerous abscesses or purulent depots are found in 
various organs and tissues, which are called metastatic or multiple 
abscesses. They are most common in lungs and liver, then in the 
spleen, and lastly in brain, heart, and kidneys. I have several times, 
in lying-in women, seen enormous collections of this kind in the cel- 
lular tissue of arms and legs, beneath the skin. 

These abscesses are seldom if ever single, and may amount to 
several hundred, varying from the size of a hemp-seed or pea, up to 
the size of a quart measure. 

These abscesses never contain well-formed pus, but a dirty-grayish, 
drab, or ash secretion, and composed mainly of a plastic lymph. 
There is rarely any appearance of inflammation around them. 

Treatment. — Little need be said on this point, as the disease is 
always fatal. Stimulants, tonics, and anodynes, are the only indica- 
tions suggested by the symptoms. 

HECTIC FEVER. 

Hectic Pever is a peculiar form of fever which never occurs as an 
idiopathic affection, but is always symptomatic of some particular 
disease, and is generally connected with the existence of suppuration 
of some important organ, and more especially the lungs. A striking 
characteristic is, that it rarely if ever appears until the malady which 
it represents has made considerable progress. In phthisis, it is sel- 
dom seen until the softening of tubercles takes place, and often not 
until large cavities are formed. On the other hand, we sometimes see 
large psoas abscesses without hectic for a long time. If the latter 
be opened and exposed to the air, hectic follows immediately. 

One marked difference between hectic and pyemia, is the pro- 
tracted course of the former, and short duration of the latter. 

In traumatic affections, hectic often sets in early. 

Hectic may be regarded as a continued, remitting fever, lasting 
usually as long as its cause continues in action. Although the 



HECTIC FEVER — MORTIFICATION. 19 

fever does not generally intermit entirely, it is subject to distinct 
paroxysms. Sometimes its course is rapid and violent; at others 
languid and gradual ; sometimes preceded by severe rigors, at others 
a mere sense of chilliness. Appetite and sleep are impaired ; tongue 
dry, sometimes coated and sometimes red. In a word, hectic re- 
sembles all other fevers in its symptoms. Paroxysms followed by 
copious clammy sweats, principally at night. The paroxysm eom- 
monly'comes on in the afternoon and lasts some six or eight hours, 
reappearing about the same hour next day. Often there are two 
paroxysms in the twenty-four hours, a second coming on at night, or 
in the morning. The sweating stage, as in other fevers, is accom- 
panied by much relief. 

Although much less uncomfortable between the paroxysms, the 
excitement and disagreeable feelings do not pass off entirely; the 
countenance is anxious, care-worn, and pale ; the eyes have a pecu- 
liar sparkling expression, are sunken in their sockets ; the teeth are 
pearly white; emaciation goes on rapidly, although the appetite is 
often good and digestion apparently healthy. 

As it progresses, the tongue becomes very red, raw, and covered 
with aphthae ; troublesome diarrhoea. The patient is gradually worn 
out after excessive emaciation, while the mind is clear and hopeful to 
the last. 

The prognosis is usually unfavorable; but in those cases where 
the cause can be removed, as often happens to the surgeon, this fever 
promptly disappears — sometimes within twenty-four hours. 

The indications of treatment are, to remove the cause and to sup. 
port the system by tonics, diet, and air. The tonics most used are 
quinine, tincture of bark, iodide, sulphate, and chloride of iron. 
Night-sweats are met by elixir vitriol, tannin, sponging with stimu- 
lants and astringents, etc. 

MORTIFICATION. 

By this term is meant the death of a part. The stage immediately 
preceding the death of a part, or that in which it is gradually losing 
its vitality, has been called gangrene ; while the term sphacelus is 
applied to the complete extinction of life. Mortification is there- 
fore a sort of generic term, including the whole process. 

Mortification may be acute or chronic^ moist or dry. Acute and 
moist are merely names for the same thing, and so with dry and 
chronic. Specific mortification is that which arises from the action 
of a specific poison, snake-bite, chancre, malignant pustule, etc. 



20 SYLLABUS. 

Acute mortification may attack all parts of the body, with, per- 
haps, the sole exception of the heart. The susceptibility of tissues, 
however, differs greatly. As a general rule, those are most liable to 
suffer which stand lowest in the scale of organization, and which 
have little vitality. Fibrous membranes, tendons, ligaments, carti- 
lages, and bones generally perish readily; the cellular tissue is also 
very liable to suffer. Next in order come the mucous and serous 
membranes, the lymphatic ganglions, muscles, nerves, and blood-ves- 
sels, the latter of which mortify with great difficulty. 

Mortification is extremely rare in internal organs; rarely in the 
lungs, and still more rarely in liver, spleen, kidneys, uterus, ovaries, 
and brain. 

The causes of acute mortification are those of inflammation, and 
may be thus divided : — 

1st. Intense inflammatory action. 

2d. Mechanical obstruction of circulation. 

3d. Chemical agents. 

4th. Defect of nervous energy. 

5th. Constitutional debility. 

Symptoms. — These are much aggravated when acute inflammation 
is about to terminate in gangrene ; sensibility and pain are increased ; 
redness becomes more vivid ; swelling and tension increase ; effusion 
and disturbance of function more marked. 

Constitutional symptoms also are aggravated; fever is much in- 
creased and accompanied by delirium; pulse rapid; thirst great; 
great restlessness. In young and robust subjects the symptoms are 
sthenic; in weak subjects the reverse occurs. Under any circum- 
stances prostration soon occurs, with irritable pulse, surface bathed 
with cold perspiration, sunken countenance, etc. 

The complete death of the part is denoted by the livid, black, or 
mottled discoloration, by entire absence of heat and sensibility ; a 
peculiar fetid, cadaverous odor, and crepitation on pressure in con- 
sequence of chemical decomposition of the tissues. Immediately 
beyond the seat of mortification the inflammatory action, with its 
attending phenomena, is seen still going on. 

The constitutional symptoms now become very marked. 

The color of the mortified parts varies in different organs. 

The consistence also varies. 

The effects of mortification on the system vary according to cir- 
cumstances. 

In those cases where the powers of the system are sufficient to re- 
sist and arrest it, an attempt is made by nature to throw off the dead 



MORTIFICATION. 21 

from the living parts by ulcerative action, the first evidence of which 
is seen in the formation of a circle of vesicles filled with sero-san- 
guinolent fluid. These vesicles burst, and a faint, reddish line is 
observable, technically called the line of demarkation, which is 
looked for by the surgeon with great anxiety. This process is the 
commencement of spontaneous amputation, which sometimes proceeds 
with considerable rapidity. 

The skin generally separates first, then muscle, tendon, and aponeu- 
roses, then vessels and nerves, and lastly, cartilage and bone; the 
latter being detached with great difficulty. Frequently several months 
elapse before the separation is complete, and then in a very irregular 
shape ; in a limb the stump is conical, with the bone projecting be- 
yond the other tissues. 

The discharge during the process is profuse, and extremely offen- 
sive. 

As the separation goes on, healthy granulations spring up from the 
raw border, pouring forth an abundant supply of healthy pus. 

The manner in which the divided blood-vessels are closed and 
hemorrhage is prevented, is very curious and interesting. Before 
the arteries and veins are divided by the ulceration, the blood coagu- 
lates within, lymph is thrown out around them, and they become 
hermetically sealed. This closure sometimes extends several inches. 

Treatment of acute mortification is to be conducted on general 
principles applicable to that of inflammation. 

In robust subjects, where the action is high, we deplete by bleed- 
ing, leeches ; use antimonials, saline mixtures ; give opium to allay 
pain, allay nervous excitement, and procure sleep ; and apply sooth- 
ing lotions, cold or warm applications, and poultices ; some recom- 
mend highly the application of blisters. Free incisions into the 
sloughing part are useful in relieving tension and discharging pent- 
up fluids. 

After mortification has taken place, when a part of any extent or 
importance is involved, the local treatment is of little importance ; 
but all the powers of life being depressed, it is important to sustain 
the system by stimulants, tonics, nourishment, opiates, etc. Quinine, 
bark, carbonate of ammonia, brandy, wine, and opium, all come into 
play, and must be used as indicated. 

Great cleanliness is important; free ventilation and the use of 
chlorides ; Labarraque's disinfecting liquid - is very convenient, sprin- 
kled over the part, the bed : poultices, etc. The yeast poultice, char- 
coal poultice, and dilute pyroligneous acid are also much used. 

3 



22 SYLLABI)?. 

The dead slough may be cut away with much advantage from time 
to time, but care should be taken not to touch the living tissues. 

When a clean granulating surface is obtained, it must be treated 
on general principles laid down elsewhere. 

In cases of mortification of the extremities, it becomes a very nice 
question to determine the circumstances which demand amputation. 
Should it ever be performed when the mortification is progressing, 
or should it be performed only after the line of demarkation is estab- 
lished ? 

It is now a well-established principle, that amputation should not 
be resorted to in idiopathic gangrene before the line is established ; 
and even then, if there is great prostration, it is most prudent to wait 
until the powers of life are somewhat rallied ; but if the strength is 
sufficient to bear the shock, the sooner the operation is performed the 
better, after the line is established between the dead and living parts. 

The course adopted in traumatic gangrene is very different. This 
is more rapid in its course, and there is often no time for delay. 
Where the injury of an important artery, nerve, joint, or bad com- 
pound fracture is the cause of the mortification, the sooner the ampu- 
tation is performed the better; nothing can be gained by delay, and 
a few hours may render it hopeless. 

Chronic or Dry Mortification is the very reverse of the acute ; it 
is slow in its march and wanting in humidity; the skin is very black, 
and when the process is complete, looks like a smoked tongue or 
piece of charcoal. 

One of the best types of this form is seen in what is called "senile 
gangrene," being most common in old subjects. It generally begins 
in a little bluish or purple spot on the inside of one of the small toes, 
which is soon followed by a vesicle filled with bloody serum; this 
bursts, and exposes a cold, black, and insensible surface. The dis- 
ease spreads from this point till it involves the entire foot, ankle, and 
even leg. The whole is black, dry, cold, insensible, shrunken, and 
without odor. 

Generally it is preceded and accompanied by sharp pains, lancinat- 
ing in various directions, and particularly at night. 

The constitution is commonly much implicated from the begin- 
ning ; pulse feeble, irritable, and rapid ; tongue brown, coated, dry, 
and tremulous ; digestive and other functions all deranged ; and the 
patient dies in from six to twelve weeks, of exhaustion. Few recover 
from chronic mortification. 

Causes. — One of the most common is ossification of the arteries, 
leading to the formation of fibrinous clots within, and obstruction of 



HOSPITAL GANGRENE — ULCERATION. 23 

the circulation. Sometimes the clot is formed a considerable dis- 
tance above the seat of disease, as in the popliteal or femoral artery, 
but generally in the smaller branches. 

Ergot, or spurred rye, has been known in France, Switzerland, and 
Germany, to produce chronic gangrene to considerable extent. It 
sometimes occurs without assignable cause. It may occur at all ages, 
but is most common in middle and advanced life. 

Treatment. — In some rare cases antiphlogistic treatment may be 
required, but generally the opposite plan is called for. Tonics and 
stimulants must be resorted to according to indications ; wine, brandy, 
porter, bark, iron, ammonia, opium, etc. Local applications are of 
little use; tincture of iodine, stimulating poultices, etc., have been 
advised. 

Amputation should not be resorted to till the line of demarkation 
is formed, and not then until the system is sufficiently rallied. If the 
operation is performed too soon, the patient sinks from the shock, or 
the disease attacks the stump. 

HOSPITAL GANGRENE. 

Hospital Gangrene is a form of disease with which you are not 
likely to meet, and need not therefore occupy your time in a limited 
course like ours. It is a variety of mortification, with ulceration, 
which commits great ravages among the wounded in hospitals and 
camps in Europe. You will find it fully described in all the sys- 
tematic works on surgery. 

ULCERATION. 

The true nature or process of Ulceration has caused much discus- 
sion. Gangrene deals with larger masses, while ulceration seems to 
act on the molecules of the part and may be regarded as a molecular 
death or destruction of tissues. In ulceration there is first softening, 
next disintegration of the affected tissue, and lastly, the removal of 
the dead or cast-off particles; but inflammation is always the first 
step which leads to the others. 

John Hunter believed that absorption was the principal act in the 
process of ulceration, and this opinion was long held by his succes- 
sors ; it was supposed that the effete particles were thus taken into 
the circulation and thrown off by the emunctories. 

Some structures are far more liable to ulceration than others; for 
instance, the dermoid and mucous cartilages and bones, lymphatic 
ganglions, tonsils, uterus, lungs, and kidneys. The fibrous and serous 



24 SYLLABUS. 

membranes, the muscles, tendons, vessels, nerves, brain, heart, liver, 
and spleen, salivary, prostate, and thyroid glands, seldom suffer in 
this way. 

Newly-formed parts, as cicatrixes and callus of broken bones, are 
easily affected by ulceration, particularly in a vitiated condition of 
the system. Ulceration is also more common in one part of the same 
tissue than in another, as in the skin, mucous membranes. 

Common and Specific inflammation. 

Definition. — Ulceration varies in the rapidity of its progress. 

Causes of ulceration are those of inflammation; any kind of in- 
flammation, common or specific, malignant or non-malignant, may 
cause ulceration ; pressure will cause it ; and it is often kept up by 
dependent position. 

When the inflammation is of an unhealthy character, runs high and 
progresses rapidly, throwing off the dead tissues in masses instead of 
molecules, it is called phagedenic ulceration. 

The pain of ulceration is often peculiar and characteristic of the 
particular form. Ulceration is always accompanied by the discharge 
of matter of some kind, and the kind is much influenced by the char- 
acter of the inflammation ; it is healthy or laudable, sanious, ichorous, 
corrosive, etc. 

There is a remarkable tendency in deep-seated ulceration toward 
the nearest surface, and this is an important law ; essential struc- 
tures are thus saved, and life often preserved by it ; abscess of the 
liver will discharge through the intestine, of the lung through the 
bronchial tubes, etc. 

Progress of ulceration differs according to cause, condition of con- 
stitution, tissue involved, etc. 

Treatment. — Principal indication is to arrest inflammation and 
bring it to the point of healthy granulation. Antiphlogistic treat- 
ment. When granulations appear, they must be carefully watched. 

ULCERS. 

Definition. — A solution of continuity or loss of substance of any 
surface, external or internal, produced by inflammation and attended 
by a discharge of pus, ichor, or sanies. Thus we have ulcers on the 
mucous surfaces of bowels, lungs, bladder, etc., about the mouth and 
fauces, on any part of integuments, etc. ; but when we speak of ulcers 
without any qualification of the term, the surgeon generally alludes 
to ulcers on the external surface, and more particularly those on the 
lower extremity, below the knee, where in the great majority of cases 
they occur, for reasons we shall soon give. 






ULCERS. 25 

The subject is one full of difficulties, as you may judge from the 
fact that surgeons differ greatly in their ideas of its pathology, 
classification, and treatment. Many of the divisions of ulcers are so 
minute as to confuse the student, and not being based on any fixed 
principles recognized by the - profession, they are unstable, and calcu- 
lated to mislead. Take up a dozen elementary works on surgery, 
and you will find scarcely any two to agree, which shows that they 
are all talking of things they do not fully understand. 

All ulcers are the result of inflammation, acute or chronic, simple 
or specific, and must be judged in all cases by the degree, character, 
and results of inflammation. 

The division, therefore, of Dr. Gross, is the most simple, most 
natural, and in every respect the best for the young student. He 
divides ulcers into " acute and chronic, according to the intensity 
and rapidity of the morbid action." 

Common or simple ulcers are those which are produced by com- 
mon inflammation, wounds, abrasions, etc. Specific ulcers are those 
which owe their origin, or at least character, to some specific virus, 
as small-pox, syphilis, glanders, malignant pustule, schirrhus, encepha- 
loid, tubercle, melanosis, and a variety of animal and vegetable 
poisons. 

Acute Ulcers. — The name indicates the character; they are dis- 
tinguished by severe and rapid inflammation. They usually spread 
rapidly from a point, generally oval in shape, but sometimes irregu- 
lar, surface very red and angry looking, or red at one point and 
covered by white aplastic matter at another. When the action is 
very high, the bottom of the ulcer exhibits a foul, greenish, brownish, 
or blackish appearance, without any semblance of healthy lymph; 
the discharges are profuse, bloody, acrid, and possessing none of the 
characters of healthy pus, such as is furnished by a granulating 
wound. 

The edges of this kind of ulcer differ much in different cases ; in 
general they are thin, sharp, and undermined ; or undermined at one 
place, straight at another, and, perhaps, everted at a third ; some- 
times very ragged. 

The parts around exhibit all the marks of high inflammation ; deep- 
red color; preternatural heat ; oedematous swelling and pitting. The 
pain is often very acute, and varies much in kind, throbbing, pulsat- 
ing, gnawing, pricking, dull, heavy, etc.; much aggravated by posture. 

Together with the above phenomena there is often much constitu- 
tional disturbance, fever, loss of appetite, deranged secretions, etc. 



26 SYLLABUS. 

Persons of bad habits, irritable temperaments, those laboring under 
mental anxiety, exposed to bad atmosphere, are most liable to in- 
flammatory ulcers ; rarely seen in children or in the higher circles of 
society; they are usually diseases of the poor and the vicious. 

Acute ulcers may be primary, or one of chronic character may as- 
sume this type from various local or constitutional influences ; some- 
times spreading very rapidly and destroying all the surrounding 
tissues; in other words, assuming the phagedenic type. Here the 
molecular death is akin to mortification, both in local and constitu- 
tional symptoms. 

Treatment of acute ulcers must be strictly antiphlogistic, modified 
to suit the particular case; mercurials where the secretions indicate 
them, purging, neutral mixture, antimonials, opium to allay pain and 
procure sleep. 

Other cases, instead of antiphlogistics, require tonics, generous diet, 
stimulants, etc. The history of the case, pulse, constitution, and con- 
dition of the patient must guide us. 

Local Treatment. — This is directed by the general principles 
already laid down for inflammation. . Rest and position are of pri- 
mary importance; scarifications and the application of warm wet 
cloths to promote bleeding are sometimes required. Poultices, 
sprinkled with opium or morphia, give great relief; touching with 
acid nitrate of mercury, or nitrate of silver occasionally; warm- 
water dressings ; chlorides to correct fetor-; charcoal or yeast poul- 
tice for same purpose. 

Under these remedies inflammation subsides, the ulcer cleans, and 
granulations appear, and new skin commences forming along the 
edges of the old. When this stage arrives, the simplest and mildest 
dressings are best, and if stimulating applications are used they must- 
be mild and watched carefully. 

Chronic TJlsers. — The exact point at which an acute merges into 
a chronic ulcer cannot be well defined ; and it must be remembered 
that chronic inflammation may at any time, under certain influences, 
become acute, and require the treatment of acute inflammation. This 
is seen well illustrated in inflammations of the eye. Chronic ulcers 
are peculiarly liable to these changes ; for, occurring as they generally 
do on the lower extremities — in the laboring class and among the in- 
temperate and reckless — they are in the great majority of cases sub- 
jected to numerous irritating influences. The term chronic generally 
includes the idea of time, but usually is applied to inflammations of 
low, sluggish type, whether of long or short duration. In the re- 



ULCERS. 21 

ceived sense, therefore, an ulcer may be chronic almost from the 
beginning ; may become so in two or three weeks, or as many months. 
Generally speaking, chronic inflammation is the sequel or result of 
acute inflammation. 

In the chronic form the symptoms become much mitigated, the 
redness, heat, swelling, and pain all are greatly diminished; the parts 
are still engorged with dark blood and surrounded by effused fluids ; 
there is no tendency to reparation, and the ulceration often pro- 
gresses. 

Chronic ulcers may exist for months, or even years, advancing, 
stationary, or receding according to circumstances. Granulations, 
when they occur, are feeble, unhealthy, and incapable of carrying on 
reparation without proper aid from the surgeon. 
' In chronic inflammation the constitutional symptoms are changed, 
fever disappears, the pulse subsides, and the system, like the ulcer, 
demands support; and it is clear that the case must be treated in 
accordance with the general principles already laid down. 

Though varying very much in seat, as well as number, shape, size, 
color, etc., chronic ulcers are most commonly found on the inner sur- 
face of the leg, a few inches above the ankle, sometimes on the oppo- 
site side, over the joint, or higher up. This choice of position is 
difficult to explain ; there are more veins on the inside, and this is the 
only plausible reason assigned. 

Chronic ulcers differ greatly in size and shape, sometimes round or 
oval, irregular ; sometimes small, at others covering half the leg. In 
depth, they generally do not reach below the subcutaneous cellular 
tissue ; at other times they involve the fascia, muscles, and even bones 
and cartilages. 

The color of these ulcers varies from pale red to purple or brown, 
according to the condition of the circulation. The color or degree 
of vascularity of the surrounding integuments also varies much. 

The edges are generally callous, elevated, rather broad and insen- 
sible; more rarely they are thin, serrated, and either inverted or 
everted, and very sensitive ; sometimes the edges are undermined ; in 
fact, there exists almost every possible variety, which must be studied 
in hospital wards to be fairly understood. 

The surface of the ulcer is irregular, and more or less below the 
edges. "When there is much inflammation there is an absence of 
granulations, and the bottom of the sore will be found foul, fetid, 
bloody, and even phagedenic, or covered with unhealthy lymph, in- 
capable of organization. The discharges are profuse, acrid, sanious, 
and not presenting the appearance of pus; sensibility often great. 



28 SYLLABUS. 

This form of ulcer is often truly chronic, may exist for an indefinite 
time, and is what authors have called the inflamed or irritable ulcer ; 
it is most common in nervous, irritable constitutions and the intem- 
perate. Where the inflammation is more languid, granulations of a 
weak, flaccid character will sprout up, and often high above the skin, 
requiring to be cut down before healing can commence; they are 
pale, flabby, and tuberculated. This is vulgarly called proud flesh, 
and ulcers of this kind have been called weak ulcers. Sometimes 
chronic ulcers are seen with very small florid granulations, irregular 
in shape and exquisitely sensitive and painful ; the discharge is thin, 
sanious, and acrid; the surrounding skin is much inflamed, and the 
whole mass looks angry and unhealthy, with irregular edges. Chronic 
ulcers are often complicated, and kept up by visceral or constitutional 
disturbance and by local complications of fascia, veins, bones, etc., 
as well as by bad habits or occupations. 

Treatment. — The causes or complications are first to be removed ; 
the inflammatory action must be attended to and granulation pro- 
moted. The surgeon must view the case deliberately, meet the indi- 
cations, and not look for specifics. Whatever is wrong in the sys- 
tem must be corrected, and the question determined whether the 
action is above or below par, and whether tonic or antiphlogistic 
remedies are needed. 

Where the edges are undermined, the shortest way is to cut them 
off; where the granulations are too high, they must be destroyed by 
caustics. 

Where ulcers are too sensitive to bear compression and are in- 
flamed, a poultice of bread and milk, starch and corn meal, ground 
flaxseed, slippery elm, or similar soothing materials, afford great com- 
fort, and are the best protection. 

W r hen they require stimulating, they may be touched with solid 
nitrate of silver, or the acid nitrate of mercury ; wet with weak solu- 
tions of nitric acid, sulphate of copper, the muriated tincture of iron. 
When the pam is great, a little opium or morphine may be sprinkled 
on the sore or poultice. 

A great variety of ointments have also been recommended, simple 
cerate, basilicon, red precipitate, etc., and although they often answer 
exceedingly well, they are less cleanly and less used now than other 
dressings. 

During the whole treatment, the bowels, stomach, secretions, and 
general condition of the system must be attended to ; without this, 
local remedies are often of no avail. 

When healthy granulations appear, the treatment becomes very 



GRANULATION. 29 

simple ; here it is that ointments answer best, either mild or stimulat- 
ing, according to the condition of the sore. 

In all forms of ulcer, elevated position of the part, and rest, 
greatly facilitate the cure ; in the inflamed, and all those which will 
not bear compression, it is indispensable. There are, however, many 
chronic, very indolent and insensible ulcers which admit of a modifi- 
cation of this treatment. Among the poor and laboring class, time 
is too valuable to lose, and among these you often find ulcers which 
are extremely indolent, and which bear compression well; in such 
cases by supporting the parts well with a bandage or adhesive straps, 
or both, the patient may be allowed to go about moderately, and the 
treatment be successfully conducted. 

Manner of dressing ulcers generally — cleansing, changing dress- 
ings, etc., use of chlorides. 

Propriety, danger, etc., of healing chronic ulcers. 

GRANULATION. 






This is the process by which all wounds heal that do not close by 
first intention or adhesive inflammation, and is the only one by which 
ulcers can be healed. It is a process of great interest and import- 
ance to the surgeon, and should be thoroughly comprehended by the 
student. Inflammatory action, to a certain extent, is necessary for 
the formation of granulations, but this inflammation must neither be 
too high nor too low. When a proper, healthy action is established 
in an ulcer or open wound, the surface becomes covered with a layer 
of lymph, which soon becomes organized and converted into florid, 
fleshy-looking little bodies called granulations. Successive layers of 
deposit go on becoming organized in this manner, until the raw sur- 
face is filled up and covered over by a new skin or cicatrix. 

The progress of granulations viewed under the microscope is very 
curious ; but this we must leave to the professor of pathology. They 
are usually very florid, very vascular, very sensitive, and bleed upon 
the slightest touch; they are conical, rounded, or oval in shape, and 
not unlike a ripe strawberry or half-ripe blackberry; the blood-ves- 
sels are very minute and numerous, forming delicate loops in each 
point of granulation ; they often form with great rapidity ; they ab- 
sorb readily many substances in solution, as opium, arsenic, quinine, 
etc. I have often allayed pain and procured sleep by the absorption 
of morphine in this way ; atropia applied in this way will dilate the 
pupils, and strychnia produce its specific effects; and so with other 
articles. 



30 SYLLABUS. 

Granulations also are secreting bodies; they pour out lymph, a 
part of which goes toward the reparation of the part, and the other 
to the formation of pus for the protection of the part from the atmo- 
sphere, and often to form a protecting scab. 

The facility with which granulations form depends upon the struc- 
ture of the part, the degree of inflammation, condition of the consti- 
tution, and other circumstances. Ulcers involving the skin and cellular 
tissue usually throw them out with great facility; bones, cartilage, 
tendon, and fibrous membranes, on the other hand, granulate slowly 
and with difficulty, on account of the less vascularity and deficiency 
of sensibility, and their injuries are consequently repaired with more 
difficulty. 

Granulations may be quite healthy at one time and the reverse at 
another, and the change may depend on some derangement of the 
system, imprudence of the patient, improper dressing, etc.; and the 
appearance of the granulations are an important guide to the sur- 
geon in his treatment. 

Healthy granulations are very small, florid, and sensitive, without 
pain unless when touched. When unhealthy they become too pale, 
too dark and congested, too soft, too hard, too sensitive, or too in- 
sensible ; sometimes they become cedematous ; at others too exuberant 
or deficient. 

The character of the discharges from granulations also varies greatly ; 
from healthy granulations we have healthy pus, thick, creamy, of pale- 
yellowish color. From inflamed or irritable granulations the dis- 
charge is thin, bloody, and acrid. In old callous granulations there 
is generally little or no discharge at all. 

In the treatment of granulating surfaces, it is important to protect 
them from the air, to prevent them from becoming too dry or un- 
healthy, and thus embarrassing the healing process. Simple water 
dressings, emollient poultices, or simple ointments, all answer well for 
this purpose. 

CICATRIZATION. 

Cicatrization is the term applied to the process by which the open- 
ing is closed and covered over by a new product. 

When a wound or ulcer is about to close or heal, it becomes 
covered over and filled up with healthy granulations ; a thin, white 
layer of lymph is deposited around the edge of the old skin or sound 
margin; this becomes organized and covered over with epithelial 
scales ; at first it is a very thin, delicate pellicle of whitish or bluish 
color, easily wiped off; very soon it becomes thicker and firmer, and 



CICATRIZATION — SOFTENING, ETC. 31 

assumes a good deal the character of the deficient integument whose 
place it is to supply. The process thus goes on steadily, new skin 
forming from the margins, until the whole surface is covered over by 
a cicatrix. 

In the great majority of cases the cicatrix is formed by, or from, 
the margins of the old skin, and does not form in the central parts 
of the sore. Many surgeons assert that this is always the case ; but 
there are, unquestionably, occasional exceptions, where patches of 
skin or cicatrix will form on the central granulations, entirely inde- 
pendent of the integuments. 

It requires some time for the cicatrix to become firm ; it makes a 
very good substitute for the true skin, but is never identical in struc- 
ture. It has a tendency to contract, to crack or break, and ulcerates 
again or inflames from more trifling causes than the original skin. 
An old scar on a horse's back is the first point to become sore under 
the saddle. 

The same remarks apply to other tissues than the skin; except 
bone, there is scarcely an example where a tissue is repaired by 
material identical with the old. 

Cicatrixes are sometimes attacked by the epithelial form of cancer, 
keloid, ill-conditioned ulceration, etc. 

SOFTENING, INDURATION, TRANSFORMATIONS, HY- 
PERTROPHY, ATROPHY, CONTRACTION. 

These are terms frequently met with, and should be understood 
by the student ; they are the result of excess, deficiency, or perver- 
sion of nutrition. 

Softening, or, as the French call it, ramollissement, is often a re- 
sult of inflammation, and may occur in almost any organ or tissue. 
It is characterized by a want of that natural firmness or solidity 
which belongs to an organ in its normal state, and varies much in 
degree, from a slight loss of consistence to a state bordering on 
fluidity. The lungs, brain, spleen, liver, heart, mucous membrane of 
alimentary canal, articular cartilages, and spongy portions of bones, 
are points of its attack. Softening may take place rapidly or slowly, 
and has therefore been divided into acute and chronic. It depends 
mainly upon the vascularity of the tissue and the acuteness of the 
inflammation. 

The cause and nature of softening are often difficult to understand ; 
interruptions to the supply of blood, or nervous influence, are some- 
times evident causes. 



SI 



32 SYLLABUS. 

Induration is usually one of the events of inflammatory action, 
and is the result of the deposition of lymph in the substance of an 
organ; its interstices are filled up; it becomes harder and heavier; 
the lymph may be absorbed and removed entirely, or may become 
organized and give rise to permanent induration. 

It is very common, and may occur in any of the tissues; lungs, 
bones, uterus, subcutaneous cellular tissue, and glandular system are 
most liable. 

Differs greatly in extent, degree, consistence, persistence, rapidity 
of formation. 

Greatly impairs the structure and functions of organs. 

Treatment of induration. 

Transformations of Tissues. — Some of these in the young and 
growing are normal; those of the adult are abnormal. 
The most important changes to the surgeon are the — 

Cellular; 

Mucous ; 

Cutaneous ; 

Fibrous ; 

Calcareous ; 

Fatty. 

Hypertrophy. — This term is applied to the enlargement or in- 
creased size of an organ. True hypertrophy is not usually a diseased 
but a healthy process, the result of an attempt of nature to compen- 
sate for some defect of action, although other examples have been 
admitted. The causes assigned are inordinate exercise of an organ, 
mechanical obstruction, and chronic inflammation. 

Examples of each. 

Atrophy is a term, on the contrary, applied to the wasting or 
diminution of an organ. 
Causes, nature, examples. 

Contraction and Obliteration. 

Synonymous with stricture. 
Nature, causes, symptoms, etc. 

TUMORS. 

From the frequency of their occurrence, their great variety, and 
their important relations, local and constitutional, this class of affec- 
tions is one of great importance to the surgeon. 



" 



TUMORS. 33 

A tumor may be defined "a circumscribed mass, growing in some 
tissue or organ of the body, and dependent on a morbid excess or 
deviation of the nutrition of the part." It increases in size by an 
inherent force of its own, independent of the structure of the part in 
which it grows. 

Tumors are divided into two great classes, viz., non-malignant and 
malignant. The boundary between the two cannot be clearly de- 
fined, and a simple, under certain circumstances, may degenerate into 
a malignant tumor. We therefore have another term in use, the 
semi-malignant, to designate the intermediate condition. The non- 
malignant, simple, innocent, or benign tumors are strictly local, and 
resemble more the normal textures of a part, and are therefore called 
homomorphous. They usually grow slowly, and are more or less 
distinctly circumscribed, being often inclosed in a cyst, and have no 
tendency to involve surrounding structures in their own growth; they 
simply affect the other tissues by their size and pressure. 

There may be one or more ; when removed they have no tendency 
to return, and when left alone often attain large size. 

The truly malignant tumors differ in toto from the benign. They 
seem to depend on some vice of the constitution, or if local in the 
beginning, they soon involve the system. They are characterized 
also by much greater activity in their progress than innocent tumors. 
They commence at a point from an unknown germ or cause, are 
developed by an inherent force of their own, irrespective of the sur- 
rounding tissues, and produce a mass which differs entirely in appear- 
ance and structure from any normal tissue in the body, and hence 
called heteromorphous. This mass may be confined in a cyst, or in- 
filtrated in the texture of some organ, and usually increase with great 
rapidity. 

Malignant tumors also have the peculiarity of involving the sur- 
rounding tissues without shoicing any well-defined boundaries, and 
soon implicate other organs through the lymphatics or blood. If 
removed, they return either in the same site or in some distant part 
of the system. If left alone, they march steadily on, increasing in 
size, ulcerating, destroying the tissues around, and causing death by 
the local injury, implication of other organs, and constitutional dis- 
turbance. 

Malignant tumors are usually cancerous in their nature ; but malig- 
nant and cancerous are not synonymous terms; every malignant 
tumor is not cancerous, though every cancer is malignant. Some 
cartilaginous, fibro-plastic, and other tumors become malignant, and 
return when removed, although to the naked eye or the microscope 



34 SYLLABUS. 

there is no cancerous structure visible. I have seen cases of this 
kind repeatedly, where I was unable to decide upon the probable 
issue. This malignant termination or degeneration of apparently 
innocent tumors probably depends upon some peculiarity of the 
individual. 

Non-malignant tumors may be arranged in three classes :— 

1. Encysted tumors. 

2. Tumors dependent on the simple increase of size of already 
existing structures in the tissues or organs in which they occur ; for 
instance, fatty tumor in adipose tissues, exostosis in connection with 
bone, etc. 

3. Tumors dependent on the new growth of already existing 
structures in situations where they are not normally found ; as for 
instance a cartilaginous tumor in the midst of cellular tissue, or a 
fibrous tumor under a serous membrane, etc. 

Encysted Tumors may be divided into — 1st. Those dependent 
upon the gradual accumulation of a secretion in a naturally existing 
duct or cyst, with dilatation and hypertrophy of its walls. 2d. Those 
that result from the new formation of a closed cyst in the cellular 
tissue of the part and the destruction of it by the secretion from its 
lining membrane. Examples of the first are seen in encysted tumors 
of skin and cellular tissue formed by sebaceous follicles from closure 
of their ducts; in the sublingual and mammary glands from same 
cause; and those formed by the retention and modification of the 
secretions in cysts without excretory ducts, as in the bursse. 

Encysted tumors arising from the obstruction of the excretory 
ducts of the sebaceous glands include the various forms of athero- 
matous tumors on the surface of the body, on the scalp, neck, face, 
back, etc. ; they vary much in size ; very common in the eyelids ; 
sometimes very numerous in the same subject. 

Symptoms, anatomical characters, progress, diagnosis. 

The treatment is removal. 

Other forms of encysted tumor may arise from the closure and 
dilatation of the ducts of other excretory organs, as ranula, encysted 
hydrocele, in the testicle, female breast from lacteal ducts. 

Cysts from the distention of cavities unprovided with ducts are 
numerous, as bursse ; these vary much in size, structure, and appear- 
ance. Cysts are sometimes new formations ; simple and compound, 
or multilocular cysts. Contents ; treatment. 

Encysted tumors containing hair, teeth, fatty matters, etc. ; re- 
mains of blighted foetus; they are congenital. 



CANCER. 35 

Tumors from the simple growth of tissues are quite common. 
They comprise those — 1st. Connected with the integurnental struc- 
tures, as warts, polypi, etc. 2d. Lobular hypertrophies, with more or 
less modification of glandular structure, as in the breast. 3d. Fatty 
tumors. 4th. Vascular tumors. 5th. Tumors of nerves. 6th. Tumors 
of bones. 

Warts, condylomata, keloid. 
Treatment. 

Elephantiasis. 

Polypi. 

Hypertrophy of glandular structures, as lymphatic glands, lym- 
phatics, testes, etc. 

Fatty tumors. 

Fibro-cellular tumor. 

There is another class of tumors depending on the new growth of 
structures identical with, or very closely resembling normal tissues, 
in situations where they are not normally found. 

This class includes many innocent growths, but some that are semi- 
malignant. The fibrous, fibro-plastic, and the enchondromatous 
tumors are those chiefly met with. 

Fibrous tumors occur in various parts of the body, but are not so 
common as many other forms ; they are irregularly oval or rounded, 
smooth, movable, painless, slow in growth, but may attain large size. 
When cut into they exhibit a fibrous structure; they often remain 
stationary for years, but finally undergo disintegration, soften and 
break down, ulcerate and slough ; they throw out fungous growths, 
suppurate externally, and bleed, and finally wearing out the powers 
of life. 

The semi-malignant often resemble these very much, and have 
been termed malignant fibrous, recurring-fibroid, fibro-plastic, and 
the enchondromatous. 

Malignant fibrous tumor. 

Fibro-plastic or myeloid tumor. 

Recurring-fibroid tumor. . 

Enchondroma, or cartilaginous tumor. 
Symptoms, structure, etc. of each. 

CANCER. 

This is essentially a malignant growth, has a tendency to return 
when removed, implicates surrounding structures, and if not consti- 



w 



36 SYLLABUS. 

tutional in its origin, soon involves other organs and the whole 
system. 

Cancer differs from all normal structures by being a new pro- 
duct, never under any circumstances existing in the healthy system, 
and possessing laws and organization peculiar to itself. 

Cancer presents itself in four or five forms so different in appear- 
ance, in rapidity of growth, in consistence, color, and structure, as at 
first sight to appear to constitute essentially different diseases, but 
yet having so close a family resemblance, and presenting so many 
points in common, that, physiologically and pathologically, they must 
be considered as mere varieties of the same disease. The varieties 
of cancer generally admitted are schirrhus, or hard cancer ; ence- 
phaloid, or soft cancer; colloid, or gelatinous cancer; melanosis, 
or black cancer. 

Symptoms, progress, structure, etc. of each. 

Diagnosis not always easy. 

Causes of cancer. 

Treatment of cancer — caustics, excision, etc. 

When to be operated on. 

Epithelial Cancer — Epithelioma. 

In what does it differ from other cancers ? 

Where found usually. 

Treatment — caustics, excision, etc. 

SCROFULA. 

Scrofula, struma, tubercular disease, are synonymous terms, and 
are applied to a peculiar condition of the system, which soon or late 
ends in the deposition of a peculiar matter called tuberculous, in 
some one or more organs or tissues. There is, perhaps, no tissue in 
the body exempt from its ravages ; its most common forms of mani- 
festation are pulmonary consumption, chronic enlargement of the 
glands of the neck, and other parts, hip-joint disease, psoas, lumbar, 
and other chronic abscesses connected with bones and joints, follicu- 
lar ulceration of mucous membranes, arachnitis, otorrhoea, ozgena, 
ophthalmia, eczema, etc. 

The striking characteristic of scrofula is the deposition of tuber- 
cular matter, but still a strumous disposition of the system may exist 
giving rise to various derangements of organs, or the system gener- 
ally, without reaching the point of tubercular deposit. 

It is now generally conceded that scrofula and phthisis are the 
same disease, the different forms depending solely on the structure 



SCROFULA. 



37 



attacked. The tubercular matter found in a lung, bone, or gland is 
the same. Tubercular disease not only occurs at all periods of life, 
but is most frequently hereditary. When it attacks the lungs it is 
most common between the twentieth and fortieth years. In children 
it is most common between the third and tenth year. Children suffer 
little from phthisis, and adults comparatively little from external 
scrofula. The disease rarely occurs in any form in those advanced 
in life. 

The children of consumptive parents often suffer with scrofulous 
diseases of bones and joints, lymphatic glands, eye, ear, serous mem- 
branes, skin, etc. 

Attacks whole families ; sometimes skips a generation or two. 

Tubercular deposit. — Its characters and mode of deposit. 

Causes of tubercular disease. 

Scrofulous or tubercular deposit is always accompanied by inflam- 
mation, but of a low and peculiar kind. 

Duration — indefinite. 

Symptoms. — Excessive emaciation of all the organs; blood is 
altered, thin and deficient in globules. 

Not contagious. 

The strumous diathesis is declared by certain external, as well as 
internal signs ; it presents two physiognomies. 

In one the complexion is brunette : hair more or less dark ; pupils 
large ; upper lip tumid ; face pale and puffy ; hands and feet disposed 
to be cold ; body sensitive to changes of temperature ; muscles weak ; 
intellect sluggish; appetite capricious; digestion irregular; bowels 
loose or bound. Children of this type particularly prone to scalp 
eruptions, enlargement of tonsils, and discharges from ear. 

In the other form a very opposite condition of mind and body is 
seen: complexion very fair and florid; eyes blue; hair blonde or 
red ; mind precocious and very active ; cutaneous circulation active. 
In this form of struma, the bones and joints, eye, skin, lymphatic 
ganglions, are the parts most liable to suffer; phthisis being more 
rare than in the dark variety. 

Scrofulous Ulcer. — Common on skin; best marked in lymphatic 
glands ; its characteristics are 

Treatment of Scrofula. — Depends much on the individual case and 
peculiar state of the system ; at one time antiphlogistics ; at another 
tonics. 

Mercury, iodine, iron, quinine, cod-liver oil, purgatives, diet, cloth- 
ing, exercise and air, travel. 

Local treatment; their uses and abuses. 



38 SYLLABUS. 



SYPHILIS. 



This disease may very properly be studied in connection with 
scrofula; for although there are many striking points of contrast, 
still they both are very chronic in their march; both pervade the 
whole system and attack nearly every tissue in it ; often their symp- 
toms are so blended, that a diagnosis is difficult to form, particularly 
in the osseous, glandular, and cutaneous system. Syphilis, too, is 
generally much more intractable in scrofulous subjects ; and it has 
been contended that syphilis in one generation is the parent of 
scrofula in succeeding ones. 

Syphilis commences as a sore, called chancre, of a specific char- 
acter, and, except in rare instances, about the genital organs. The 
next step is in the lymphatic glands of the groin ; then the cutaneous 
and mucous surfaces, and finally the bones, cartilages, and fibrous 
tissues, on all of which its mode of action is peculiar. The action 
is first local, and if arrested here the other organs escape. If not 
arrested in from four to six weeks, the cutaneous and mucous sur- 
faces show signs of disease, and, at a still later period, from six to 
eighteen months, or longer, the bones, cartilages, and fibrous tissues 
are attacked. To these three stages, or periods, the names of Pri- 
mary, Secondary, and Tertiary Syphilis are generally applied. 

Syphilis is peculiar to the human race, and cannot be communicated 
to animals by inoculation. The disease never arises spontaneously, 
but is propagated by a specific poison from one individual to another. 
A chancre may be produced on any part of the body by inoculation 
with a lancet. The pus, or matter of a chancre, has nothing in it 
peculiar to the eye. 

The virus acts much more certainly and rapidly when applied to a 
raw surface. When applied to a sound surface, several days elapse 
before any effect is seen, and often no effect is produced. No matter 
how applied to a surface, the effect may follow, and surgeons and 
accoucheurs should be very cautious how they touch. 

Pkimary Syphilis. 

As stated, this is the first stage, and includes chancre and bubo. So 
far, the disease is local, and the matter contagious. When it passes 
on to the secondary and tertiary stages, it is no longer communicable 
by inoculation, though transmissible to the offspring through either 
the father or mother. 

Chancre. — Its first symptom is a little red speck ; it next becomes 
elevated into a small papula, surrounded by a faint rose-colored cir- 



SYPHILIS. 



39 



cle ; about the third or fourth day, the papula assumes the form of a 
vesicle, the cuticle being elevated by a little thin, whitish matter, and 
the inflammation around increases. This stage lasts but a day or 
two, when the vesicle is transformed into a pustule, or filled with pus, 
the center being depressed. From the fifth to the sixth day, a re- 
markable and characteristic change occurs; the tissues under and 
around the sore become infiltrated with fibrin, indurated, and, when 
grasped between the fingers, feel like a mass or ball of fibro-cartilage. 
This is the mature stage at which the chancre secretes the infectious 
virus. At about the sixth day, the pustule begins to turn dark ; a 
firm, thick scab forms, stratified and somewhat conical. If the scab 
is removed, a large, deep ulcer is seen, of an excavated appearance, 
as if scooped out with a punch. The edges are steep and ragged ; 
the bottom incrusted with a grayish aplastic lymph, and its base 
hard. The discharge is generally thin, sanious, or ichorous, without 
any property of healthy pus. This is what is called an indurated, 
or Hunterian chancre, and is the form considered most dangerous 
and certain to infect the system. 

Chancres are most common on the glans penis and prepuce, par- 
ticularly beside the fraenum, the vulva, surface of vagina, and neck 
or mouth of uterus ; sometimes also attack urethra. 

It is rarely we have an opportunity of watching the stages of a 
chancre, which is usually presented to the surgeon as an open sore. 

Although the above described form is agreed upon by all as an 
unmistakable syphilitic sore, and by many is regarded as the only 
true infectious form, still most writers mention two forms, viz., the 
indurated, and non-indurated or soft chancre; all other divisions 
are untenable, as the tissue attacked or state of the system give 
character to other forms, and not different kinds of virus. 

Ricord, the great French authority, asserts that there are two dis- 
tinct syphilitic poisons. The indurated chancre alone, he says, is 
the infecting ulcer; that is, capable of secreting a fluid which can 
contaminate the system in a manner to produce secondary and ter- 
tiary symptoms. The non-indurated chancre he regards as a purely 
local affection. Though the indurated chancre is most infectious, 
still the broad ground assumed by Ricord is not yet generally re- 
ceived. It is believed by many, that the soft chancre often produces 
all the constitutional effects of the indurated. Syphilitic bubo is 
believed never to arise except as a consequence of chancre. The 
indurated chancre is rounded or oval, varying in size from the eighth 
to half an inch or more ; the induration is greater when it is seated 



40 SYLLABUS. 

on the glans, than on the prepuce, and lasts for some time after the 
sore has healed. 

The indurated chancre is usually solitary; is indolent, has little 
discharge, and almost always affects the inguinal glands. 

The soft chancre is irregular in form, generally round or oval, 
and often two, three, or half a dozen exist at the same time ; they 
occur most frequently at the free margin of the prepuce, or around 
and behind the corona glandis. They often occur in succession, as 
if from the erosion of the discharge from the first one. The surface 
of soft chancre is superficial, flat, uneven, and coated with a dirty 
whitish, or ashy deposit of unhealthy lymph; sometimes it has a 
ragged or worm-eaten appearance. When seated on the glans, the 
edges are perpendicular, as if cut out with a punch; when on the 
prepuce, the edges are ragged, irregular, and often overhanging or 
undermined. The base of the ulcer is free from induration, except 
when irritated by caustics. 

This form of chancre has a tendency to spread, particularly in per- 
sons of bad constitution or habits ; often becoming phagedenic. The 
discharge is copious and quite infectious ; it frequently, but not gen- 
erally, is followed by bubo, the disease usually limiting itself to 
one ganglion ; this inflames readily, and suppurates ; forms a large, 
ugly ulcer, secreting the same kind of infectious matter, which, by 
inoculation, is capable of producing another soft chancre. Though 
less likely to attack the system than the indurated chancre, there is 
abundant reason to believe that the matter is absorbed and produces 
all the constitutional symptoms of the other form, both secondary 
and tertiary. 

Ricord believes that the true indurated chancre can occur in the 
same individual but once ; this is doubtful, but the soft chancre may 
occur any number of times. 

Writers have described a great variety of chancres, but they are 
all modifications of the two forms noticed, by peculiar circumstances 
or constitutions ; all grades of inflammation, from the mildest up to 
sloughing, are seen in different subjects, just as happens in common 
ulcers on the legs. 

Gangrene more often attacks the prepuce and skin than the glans ; 
sometimes the whole penis sloughs off. 

Diagnosis of chancre is sometimes difficult or impossible in the 
early stages; ulcers from other causes are often confounded with 
it, and we must, to a great extent, be guided by the history, until 



SYPHILIS. 41 

some distinctive characteristic is developed. The non-syphilitic sores 
disappear in a few days if kept clean and simply dressed, without con- 
stitutional treatment. 

The non-specific sores rarely affect the inguinal glands ; if they do, 
it is within a few days, while the specific sore does not before the end 
of the third week. The point may always be determined by inocu- 
lating the patient on the thigh with the matter. 

Treatment. — The first point is to prevent if possible the absorp- 
tion of the virus into the system. This is what is termed the abor- 
tive treatment. If the specific character of the sore can be destroyed 
before the end of the fifth day, the constitution will be saved, as the 
disease, thus far, is purely local. To attain this object, some surgeons 
direct the chancre to be cut out ; others prefer escharotics ; some 
recommend the nitrate of silver to be well applied. The acid nitrate 
of mercury, or a drop of pure nitric acid, is more reliable. Care 
must be taken to protect the surrounding parts. After this, a poul- 
tice should be applied till the slough falls off. The patient should be 
kept quiet, purged, and dieted. 

If we are called too late for the abortive treatment, which may be 
tried (if there is not much inflammation) as late as the seventh or 
eighth day, other means must be resorted to. If there is much in- 
flammation, soothing, and not irritating remedies must be used. 

Cleanliness is of first importance. Washing with warm water; 
poultices ; if the sore is under the prepuce, it should be syringed out 
with warm water, lead-water, weak solution of white vitriol. When 
the ulcer is beneath the prepuce, and the latter can be drawn back, it 
is all-important that lint should be constantly interposed, and the 
latter may be kept wet with the black wash, a weak solution of tinc- 
ture of myrrh and water, zinc, tannin, or any very mild astringent ; 
the most important part of the dressing is the lint and cleanliness ; 
if there is pain, the watery solution of opium answers well. After 
the sore becomes less sensitive and requires a little stimulation, the 
yellow wash, made by putting one or two grains of corrosive subli- 
mate to an ounce of lime-water, is a very good application. 

Chancres, like other sores, when chronic, require occasional change 
of dressings. When they begin to granulate, the simplest dressings 
are best. It is often indispensable, when there is much inflammation, 
that the penis should be kept elevated and at rest. 

Constitutional Treatment. — The diet and bowels must be regu- 
lated, as well as the general condition of the system. If there be an 



42 SYLLABUS. 

indurated chancre, mercury should be resorted to at once, and con- 
tinued till the gums are touched or the sore gives way, unless some 
condition of system forbid. If there is fever it must be met by anti- 
phlogistics in all the forms required, as bleeding, purging, antimonials, 
recumbent posture, anodynes, poultices to the part, cooling lotions, 
etc. In the phagedenic form, antiphlogistics and opiates must be 
freely used, but mercury never, as it acts as a poison. In this form, 
if the mild and soothing applications do not arrest the disease, solu- 
tions of the nitrate of silver, muriated tinct. Ferri, or acid nitrate of 
mercury, become necessary to change the action. 

Gangrene must be managed agreeably to the state of the system, 
according as the action is too high or too low. The local remedies 
are the same as for other cases of gangrene. 

When the chancre is indolent, it requires the application of caus- 
tics and other stimulating articles. 

The indolent chancre often leaves behind, when heated, an indu- 
rated base, which remains for an indefinite time ; this is always 
dangerous, as the system may still become contaminated as long as 
the induration lasts. Here the use of mercury is indispensable. 

Calomel the most certain form ; manner of using it ; other forms 
of mercury. 

In the primary forms of syphilis, calomel and blue mass are gen- 
erally preferred, as more prompt and reliable in action than the 
bichloride, iodides, and other preparations. It may be regarded 
proper that mercury should not be employed in any form of primary 
syphilis if there be fever. The system, under such circumstances, 
must be cooled down and prepared for it by purgatives, salines, anti- 
monials, diet, etc. Nor should mercury ever be used in phagedena, 
or gangrene, or when there is marked irritation, local or constitu- 
tional. Mercury in syphilis is a two-edged sword, that has done 
much more harm than good in unskillful hands. 

Syphilis is often cured in its primary and secondary forms without 
mercury, and many practitioners never give it. A great many sta- 
tistics can be adduced to show that syphilis may be cured in as short 
time, and as thoroughly, without as with mercury ; but there is still 
great diversity of opinion on the point. One fact is certain, that the 
action of mercury, in some constitutions affected by syphilis, is pro- 
ductive of the most terrible effects. 

Where phymosis complicates chancre, it should not be touched by 
the knife if it can be avoided. Frequent injections of tepid water 



SYPHILIS. 43 

should be resorted to, together with occasional astringent washes, 
until the inflammation subsides. If no progress can be made in this 
way, the prepuce must be slit open to the bottom on a director, and 
the edges cauterized, to prevent infection of the cut surfaces. 

Where paraphymosis exists, it should be reduced as soon as possi- 
ble with the aid of chloroform, and if this cannot be done, the stric- 
ture must be divided and the wound covered with collodion. 

Bubo. — This is a term applied to an enlargement of one or more 
of the lymphatic glands of the groin : it is produced by different 
causes, all of which have a tendency to inflame those glands — over- 
fatigue, jumping, gonorrhoea, sores or injuries about the lower ex- 
tremities, as well as chancres or other sores on the penis, may all 
produce this affection. These swellings are most likely to occur in 
young and in scrofulous subjects. 

The syphilitic bubo differs from all these in being a specific disease, 
the result of the absorption of a peculiar virus, and in reproducing 
chancre by inoculation of the matter taken from it after it suppurates. 
Up to this point the disease is called primary, and is local. 

The syphilitic bubo rarely occurs under about fifteen days from the 
first appearance of the chancre, although there are exceptional cases 
in seven or eight days, or at the end of four or five weeks. 

Bubo may be the result of either the soft or indurated chancre. 
The indurated chancre is almost always followed by bubo, and in- 
volves several ganglions, which become indurated somewhat like the 
original sore. This form of bubo has little tendency to suppurate, 
though sure to contaminate the system soon or late. 

The soft chancre, on the contrary, is only occasionally followed by 
bubo ; it attacks usually but one gland and runs its course rapidly, 
terminating in an abscess, the matter of which is infectious. 

Some believe that a bubo may occur. without previous chancre, but 
such cases must be extremely rare, and few surgeons believe in its 
possibility. 

Buboes are sometimes hard, very chronic, and resist treatment with 
great obstinacy. In other cases they become rapidly and highly in- 
flamed, and run quickly to suppuration. In this form there is fever 
and much constitutional disturbance, with severe local pain. The 
pus should be evacuated early; if allowed to extend and ulcerate, 
they form large, ragged, angry, unhealthy-looking abscesses, burrow- 
ing under the skin, and sometimes sloughing extensively. The true 
bubo is always situated above Poupart's ligament, while the non-spe- 
cific one is situated below. 



\f 



44 SYLLABUS. 

Treatment of Bubo. — In the first stage, we should attempt the 
abortive treatment by iodine applications, and compression, with 
rest ; if this fail, some surgeons recommend deep cauterizing over its 
center, or blisters. When suppuration threatens, it should be hastened 
by hot poultices, and as soon as pus is formed, it should be evacuated 
by a free incision in the direction of Poupart's ligament. Poultices 
should follow the opening for a few days, and if the ulcer is disposed 
to become chronic, it must be stimulated by nitrate of silver, dilute 
tincture of iron, or iodine, etc. In the mean time the state of the 
system must be attended to. 

Secondary Syphilis. 

This term is applied to the next group of symptoms which follow 
the primary just described, and usually appear in from five to eight 
weeks after the appearance of the chancre. The skin and mucous 
membranes are the structures most liable to these phenomena, and 
may be attacked simultaneously or in succession, and one may be 
attacked and the other escape. Secondary syphilis is always the 
result of chancre, though not necessarily of bubo ; the latter symp- 
tom is often wanting where the worst forms of tertiary and secondary 
syphilis are manifested. 

There has been much discussion on the point, whether secondary 
symptoms follow any other than the indurated chancre. 

The secondary symptoms often occur before the primary have dis- 
appeared. The skin, mouth, and throat may show eruptions, tuber- 
cles, ulcers, etc., while the chancre still exists, or bubo. On the other 
hand, these symptoms are seen long after the primary ones are gone, 
and the patient supposes himself well. 

The indurated chancre is almost invariably followed by constitu- 
tional symptoms, and the longer the chancre remains uncured, the 
less chance of escape. Delicate and strumous constitutions are most 
likely to suffer from constitutional effects, and the chancres and bu- 
boes are here most difficult to heal. 

Dr. Gross, like many others, believes that secondary symptoms are 
more likely to occur where mercury has been used in the primary 
stage. 

When the local inflammation runs very high, absorption is less 
likely to follow. 

Transmissible by parents to the children. 

Secondary symptoms usually ushered in by well-marked constitu- 
tional disturbance, syphilitic fever, eto. 



SYPHILIS. 



45 



Secondary syphilis shows itself under the following forms, when it 
appears on the skin, viz., exanthematous, scaly, vesicular, pustular, 
tubercular, and papular, which have been termed syphilides. The 
three last appear later than the others, and belong more properly to 
the tertiary train of symptoms. 

Syphilitic eruptions are chronic in their course, are more or less 
circular in form, and always exhibit a characteristic copper hue, 
especially in their earlier stages ; later, they exhibit a dirty brownish 
or bronze, or ashy color. 

These eruptions, though occurring in all parts of the body, are 
most conspicuous generally on the forehead, nose, cheek, back, breast, 
shoulder, inside of arm and thigh, and are followed or attended by 
thin, grayish scales ; hard, thick, greenish scabs ; narrow, superficial 
cracks, or well-marked ulcers. 

These eruptions are usually easily distinguished by the history; by 
their connection with other syphilitic symptoms ; by the copper color 
of the surface, and by the absence of itching. 



V 



AC 



Characteristics of the exanthematous form. 


n 


" scaly " 


n 


" vesicular " 


n 


" pustular " 


it 


" tubercular " 


a 


" papular " 



Treatment. — Importance of attending first to the febrile and other 
constitutional symptoms, before any specific remedies are employed. 
Purgatives, antimonials, Dover's power, etc. are in the great majority 
of cases sufficient without resort to mercury, and the iodide of potassa 
is most appropriate to the tertiary symptoms. 

There are other symptoms belonging to the secondary train of 
phenomena, viz.: — 
Alopecia. 
Cervical Adenitis. 
Affections of Mucous Membranes. 
Characters of each of these. 



Tertiary Syphilis. 

This is a term applied to a still deeper grade of the disease than 
secondary syphilis, in which the poison seems to pervade the blood 
and every tissue in the system ; and it may be well doubted whether 



46 SYLLABUS. 

the constitution is ever thoroughly cleansed of the virus when the 
disease reaches this form ; it not only shows itself through life in the 
individual in some form, but the children of such subjects almost 
always bear the marks of it. 

The boundary between the secondary and tertiary forms cannot 
often be well denned. Those symptoms which occur within the first 
five or six months after the first primary symptom are usually denom- 
inated Secondary, and those which occur later, Tertiary; the latter 
being developed usually at from six to eighteen months, though not 
unfrequently occurring after the lapse of many years. 

The skin, mucous membranes, periosteum, bones, fibro-cartilage, 
aponeuroses, tendons, and testicles are the structures most liable to 
suffer from tertiary syphilis, although all others may be involved. 

Tertiary syphilis need not necessarily be preceded either by second- 
ary or bubo, but always by chancre. 

Tertiary symptoms are more likely to occur in those cases where 
mercury has been injudiciously used or abused, and such cases are 
generally the most unmangeable and distressing we have to meet. 

Influence of diathesis, habits, etc. on the development of constitu- 
tional symptoms. 



Syphilis 


of throat and mouth, 


characters of. 


it 


nose, 


it it 


n 


larynx, 


it ti 


It 


eye, 


tt it 


tt 


skin, 


it a 


tt 


osseous system, 


tt it 


It 


testicle, 


it a 


Condylomatous growths. 


a it 



Treatment. — This is much better understood of late years, and 
when not advanced too far, tertiary syphilis may generally be cured ; 
and where not curable, our remedies have great control over the 
symptoms, and contribute greatly to comfort. 

The iodide of potassium is the great remedy on which we are 
here to rely, and to a great extent it certainly is entitled to the name 
of a specific, and its use need rarely be preceded by any preparatory 
treatment. 

There has been much dispute about the proper dose of iodide of 
potassium, but from six to ten grains will be found sufficient in almost 
all cases, given three times a day in some bitter infusion or simple 
water, or sarsaparilla. In most cases, where twenty, thirty, or more 



SYPHILIS. 4tl 

grains are given, it deranges the stomach, excites the system, etc. It 
is best to produce a gradual alterative effect, and there is no truer 
maxim than the one that " a chronic disease requires chronic treat- 
ment.'' 1 

Another important direction in the administration of iodine is, to 
give it as much as possible on an empty stomach, and well diluted ; 
if we give it in a gill, or still better, half pint of water, an hour 
before breakfast, an hour before dinner, and at bedtime, the effect 
will be much more certainly attained than if it is thrown into the 
stomach while loaded with food. The fact is well known to physiol- 
ogists, that many articles may be detected in the urine in twenty 
minutes after being taken into an empty stomach, and much later and 
less certainly, if taken during digestion. The same rule, I am cer- 
tain, applies to all articles designed to act through the blood. 

The degree of toleration for this remedy differs greatly in different 
subjects ; it may continue for weeks, or even months, with the occa- 
sional omission for a few days. In many cases the effect of this 
remedy is greatly enhanced by the moderate use of the bichloride of 
mercury ; they may be combined and given together ; the eighth to 
the sixteenth of a grain of the latter three times a day. The mercury 
should be continued moderately for some weeks unless it salivates 
too much. 

Where the bichloride disagrees with the stomach, blue mass may 
be used with Dover's powder, and in some cases, where there are 
troublesome skin diseases, painful nodes, etc., Donovan's solution 
answers a good purpose. 

Fumigation, inunction, baths, tonics, sudorifics, anodynes, sarsa- 
parilla. 

Onychia, 

Syphilis of the nose, 

" " larynx, 

" " iris, ^Treatment. 

" " bones, 

" testicle, 
Condylomata. 

, Syphilis in the Infant. 

The disease may be inherited from either parent, or the child may 
be inoculated by the mother during labor. 

A chancre on the mouth of the child may communicate syphilis to 
the nipple of the nurse ; or chancre on the nipple to the child. 



48 SYLLABUS. 

There is no good reason to believe that secondary symptoms can 
be communicated from one to the other. 

WOUNDS. 

Definition.— Any solution of continuity in a tissue, by cutting, or 
pointed instrument, or any blunt substance. 
Divided into — 

Incised wounds. 

Lacerated or contused wounds. 

Punctured wounds. 

Gunshot " 

Poisoned " 

Penetrating " 

Wounds of regions. 

Complications of wounds. — Hemorrhage; foreign bodies; ab- 
scesses ; mortification ; erysipelas ; pyemia ; and tetanus. 

Mode of dressing wounds. — Adhesive plaster ; sutures ; bandages ; 
pins; collodion. 

Mode of healing wounds. — There have been described five proc- 
esses by which wounds are supposed to heal : — 

1st. By immediate union, or the direct growing together of the 
raw surfaces. 

2d. By scabbing, or the formation of a crust of blood covering 
over the wound. 

3d. By the effusion of lymph, and the conversion of this into fibro- 
cellular tissue. 

4th. By granulation and the development of epithelial matter. 

5th. By the junction or inoculation of granulations with each other. 

The doctrine of Hunter was, that there were but two processes, 
viz., healing by "first intention," or adhesion through the interposi- 
tion of lymph; and healing by granulation, or "second intention." 

Description of each of the above processes. 

Incised Wounds.— (Definition.) 

There are always present effusion of blood ; more or less pain; and 
retraction of the edges. 

Hemorrhage — Capillary, venous, arterial; color of the blood; 
arterial pulsation. 



WOUNDS. 



49 



Pain depends upon the tissue implicated ; injury of nerves, etc. 

Retraction depends also upon the tissue wounded; condition and 
age of patient, etc. 

Treatment. — The first indication in an incised wound is to arrest 
hemorrhage. This is effected by exposure to the air ; cold ablution ; 
compression ; styptics ; and ligature. 

The next indication is to cleanse the wound thoroughly of all 
foreign substance, coagula, etc.; then the cut surfaces must be applied 
together with perfect accuracy, and so retained by proper supports, 
rest, and position. If the wound is small, adhesive plaster will 
usually be sufficient; if large, sutures, pins, bandages, etc. are re- 
quired. 

Process by which the union takes place. 

If secondary oozing of blood, or undue inflammation occur, the 
union is retarded or prevented. 

Lint, wet with simple cold water and steadily applied, will combat 
the inflammation better than any other application. If suppuration 
supervenes, change to warm poultices or warm- water dressings. 

Lacerated Wounds. — (Definition of.) 

These wounds differ from the incised — in the less degree of pain ; 
in their exemption from hemorrhage ; in their tendency to inflamma- 
tion, suppuration, and sloughing ; and in their liability to be followed 
by tetanus and other nervous and constitutional symptoms. 

The absence of pain at the time of injury and soon after is attrib- 
utable to the violence done to the nerves. When full reaction, 
however, takes place, after the effects of the shock wear off, violent 
pain often sets in and requires large doses of opium. 

The absence of hemorrhage is attributable to the injury done the 
vessels and the mangled condition of the tissues enveloping them. 

Process by which the bleeding is arrested by the efforts of nature 
described. 

Treatment of lacerated wounds must be guided by same general 
principles as the incised. Hemorrhage, if present, must be attended 
to; wound thoroughly cleansed; surfaces brought nicely together; 
ragged edges trimmed off; adhesive straps, bandages, etc. applied. 
Much of the wound may not heal by first intention, but it is still 
proper to get all adhesion you can in this way, as there is less left to 
be done by granulation, and time is saved. J 

Water dressings, either cold or warm, as most agreeable to the 
feelings of patient, should be steadily applied. 

The general condition of the system must be attended to ; fever 



4 



50 SYLLABUS. 

combated; opium given freely to relieve pain and procure rest, 
etc. 

Secondary hemorrhage — how treated ; tetanus. 

Contused Wounds. — (Definition.) 

Their gravity depends upon their extent, part affected, and violence 
of the cause. The sensibility of the part is deadened, and there is 
generally little pain, till swelling and inflammation set in. 

Shock. — Its symptoms, importance, treatment. Tetanus and neu- 
ralgia sometimes follow, and, like in lacerated wounds, there is little 
hemorrhage. There is danger of secondary hemorrhage when sloughs 
separate, from fifth to tenth day. In gunshot wounds particularly 
the danger is great. 

Contused wounds suppurate freely; often slough and form ab- 
scesses, and give rise to erysipelas. 

Some of the worst forms of contused wounds are those produced 
in deep-seated parts without injury to the skin, by cannon balls, heavy 
weights, wagon-wheels, etc. 

You may have a contusion without a wound, as a " black eye" from 
the fist, etc., in which there is discoloration from extravasation of 
blood ; this is termed ecchymosis. 

Treatment. — Indications are, to arrest hemorrhage ; to combat in- 
flammation ; and promote absorption of effused blood. 

There is little prospect of healing by first intention, but it is never- 
theless proper to put the parts as much as possible in situ, and retain 
them there, so as to allow nature to do all that can be done in this 
way. After arranging the parts properly by straps, sutures, band- 
ages, etc., it is well to apply simple warm-water dressings, and, after 
a few days, lotions or poultices, a little stimulating and tonic. 

The general health must be attended to, opiates given when de- 
manded, and when granulation comes on, stimulating ointments will 
be found useful. 

Punctured Wounds. — (Definition.) 

They of course differ very much in gravity, according to their posi- 
tion, depth, extent, and parts implicated. 

The pain of punctured wounds is usually excruciating, from the 
injury done to nerves, they being lacerated, or partially torn, and not 
crushed, as in contused wounds. The pain after inflammation sets in 
is also severe ; the degree of suffering depends much on the nature 
of the inflicting instrument : a nail, splinter, or rough body of any 
kind, gives much more pain than a smooth one, like a knife, trocar, 
etc. Punctured wounds are particularly dangerous among fibrous 



WOUNDS. 51 

tissues, as in soles of feet and palms of hands, dense fascia, etc.; 
tetanus and deep-seated abscesses being common consequences. 

Punctured wounds are rarely attended by hemorrhage. The shock 
is sometimes very great. They are peculiarly liable to be followed 
by erysipelas, angeioleucitis, abscess, contraction of limbs, and wast- 
ing of muscles. 

Treatment. — First remove any foreign substance; arrest hemor- 
rhage if present ; prevent inflammation ; and quiet the nerves. The 
finger is the best probe where it can be used. 

Detection of needles, and mode of extraction ; importance of their 
removal by incision at once. 

When there is deep-seated hemorrhage, it may become necessary 
to cut down and tie the artery to prevent the formation of aneurism, 
or other effects ; artery to be tied on both sides of the injury. 

Poultices must be used; anodynes internally and locally; and it 
often becomes necessary to make free incisions where there is inflam- 
mation and swelling, or pus formed below fascia. 

Tooth Wounds. 

The gravity of the symptoms following wounds inflicted by the 
teeth of animals is usually much more marked than that of wounds 
to the same extent inflicted by other causes ; and there is good reason 
to believe that the saliva of all animals is more or less poisonous. 
The bites of dogs, cats, rats, etc., and more particularly when in- 
flicted on the hands or feet, where the structure is complicated and 
fibrous tissue predominant, are often followed by intense inflamma- 
tion of an erysipelatous character, which results in deep-seated sup- 
puration, sloughing, inflammation of lymphatics and veins, etc. The 
bite of a man, I believe, is the most poisonous of all, and I have had 
not only to amputate fingers, but an arm or two, for injuries inflicted 
by human teeth. 

Treatment consists in simple emollient applications, rest, anodynes, 
and attention to the state of the system. 

Gunshot Wounds. — (Definition.) 

Danger dependent on parts involved, extent, etc. 

Injuries inflicted by small shot, powder, wadding, bullets, cannon 
balls,' shells, splinters, etc.; percussion caps. 

Gunshot wounds partake of the nature of contused and lacerated 
wounds. The wound is small and contused at entrance of ball, and 
larger, and lacerated at exit. When the missile is large, there is 
more or less sloughing. 



52 SYLLABUS. 

Irregular course, particularly of spent balls ; ball sometimes comes 
out at the opening by which it entered. 

Balls often become encysted and remain for years without injury. 
Windage of balls. — Pain often insignificant ; injury of nerves. 
Hemorrhage generally not in proportion to the severity of the 
injury ; not likely to be serious at first except when large arteries 
are implicated; artery more likely to bleed from partial, than com- 
plete division; artery often, when struck, escapes injury from its 
elasticity ; hemorrhage external or internal. 

Secondary hemorrhage very often follows gunshot wounds, from 
separation of slough; occurs usually from the tenth to fifteenth day, 
but sometimes sooner or much later. 
Constitutional symptoms, shock, etc. 
Prognosis. 

Causes of death are shock, hemorrhage, tetanus, pyemia, erysipelas, 
gangrene, profuse suppuration, and hectic fever. 
Remote effects. 
Treatment. — The indications are — 

1st. To promote reaction and rally the patient. 

2d. To arrest hemorrhage. 

3d. To extract the ball and other foreign bodies. 

4th. To remove loose bone. 

5th. To combat inflammation, fever, etc. 

When powder is buried in the skin, it should be picked out, to pre- 
vent inflammation and discoloration ; the parts should be well washed 
and wet cloths applied. 

Amputation after Wounds. 

The decision of the surgeon must be governed by the extent of the 
wound, the parts involved, age, habits, and constitution of subject. 

Wait for reaction before operating. 

What kind of injuries demand amputation imperiously? Those 
badly complicated. 

Maggots in Wounds. 

Most common in hot weather and foul wounds. But preventives 
are cleanliness; covering the wound from flies with bran; and the 
use about the wound of turpentine, camphor, creosote, and chlorides. 

Poisoned Wounds. 

Under which head we include those inflicted — 1st. By venomous 
insects, snakes, scorpions, etc. 2d. By rabid animals. 3d. By inocu- 



WOUNDS. 53 

lation from glanders. 4th. Dissection wounds, from examination of 
dead bodies. 

Wounds of Insects. — Symptoms, treatment, etc. 

Wounds by Serpents. — Effects — dependent much on quantity of 
poison inserted. 

Symptoms. — Immediate and severe pain ; swelling to great extent in 
a short time, with mottled appearance from extravasation of blood. 

The patient soon becomes pallid; vision confused; nausea and 
vomiting; fainting fits; clammy sweats; coldness, and great pros- 
tration. 

Treatment. — Though a thousand specifics have been recommended, 
we have no reliable remedy. Persons bitten by small snakes, as the 
"ground rattlesnake," rarely die under any treatment. 

The wound should have a ligature tied above it immediately, if on 
a limb, to keep the poison from entering the circulation ; it should be 
sucked with the mouth, or scarified, and have a cup applied, and it is 
well to excise it entirely. Professor Brainard, of Chicago, recom- 
mends a solution of iodine to be injected into the wound and sur- 
rounding cellular tissue ; but unfortunately, such remedies, if really 
useful, cannot be obtained in time for successful application. 

Whisky, ammonia, and other stimulants, pushed with vigor, seem 
in many cases to have saved life, and appear to act by sustaining the 
depressed powers until the effect of the poison wears off. 

Bibron's antidote, consisting of bromine, bichloride of mercury and 
iodide of potassium, to be given internally. The experiments of Dr. 
Hammond and others are highly favorable to its curative effects. 

Wounds by Eabid Animals. — These cause a peculiar disease 
termed hydrophobia. 

The poison resides in the saliva. How produced and propagated. 

Communicated readily by animals, but not certainly by the bite of 
a rabid man. 

Period of latency — from a few weeks to several months. The 
majority of those bitten escape. 

Hydrophobia occurs in all latitudes; most common in cold or tem- 
perate climates, and rare in the tropics. 

Symptoms. — The wound generally heals kindly. When the period 
of incubation has passed, the part begins to burn, itch, become sore 
and irritable ; hot, numb, or rigid, with pains darting in various di- 
rections; sometimes a red line is seen along the lymphatics. 

5 



54 SYLLABUS. 

Together with these, local, constitutional symptoms are soon devel- 
oped ; the patient feels badly ; is restless and sleepless ; has frightful 
dreams and headache; is melancholy and depressed; occasional 
rigors. The poison now being fairly at work, explodes in a train of 
violent symptoms in some ten to twenty hours. A dread of water, 
and difficulty of swallowing, become very prominent symptoms. 

In attempting to drink, the patient is suddenly seized with spasm 
in the throat, and inability to swallow fluid; all attempts are vain, 
and he pushes the cup aside with horror. He is tormented with 
thirst, and if he succeeds in forcing down a little water, is seized with 
choking and suffocation. There is a sense of constriction of the 
throat and chest; oppression; sighing; spitting of thick, frothy 
mucus incessantly; symptoms are all aggravated, or paroxysm 
brought on by a current of air from window or door, or even a fan. 
Light and noise are both disagreeable; mind peevish and fretful; 
imagination becomes perverted; imagines sounds, etc.; looks wild; 
often becomes delirious ; screams, and gesticulates like a maniac. 

The duration of the attack is from eighteen hours to a week; 
symptoms become aggravated all the while ; the patient is gradually 
worn out ; is seized with convulsions, in one of which he usually ex- 
pires. 

Prognosis, treatment, etc. 

Symptoms of rabies in the dog, are 



Average period of incubation, forty days ; minimum, about two 
weeks ; maximum, three months ; causes, unknown. 
Has no dread of water, but drinks freely and often. 

Glanders, Farcy, or Equina. 
History; symptoms; treatment, etc. 

Dissection Wounds. 
History; symptoms; treatment, etc. 

Malignant Pustule. 
Symptoms; history; treatment, etc. 



ERYSIPELAS. 55 



DISEASES AND INJURIES OF THE SKIN, CELLULAR AND 
ADIPOSE TISSUES. 

These constitute a class of affections which it is convenient to group 
together, and among the most important of them, in the eye of the 
surgeon, is 

ERYSIPELAS. 

It is either idiopathic, or forms a complication of other affections 
or injuries. It is a peculiar inflammatory affection which was sup- 
posed to attack the skin and cellular tissue alone, but is now generally 
believed to extend to other structures, and particularly the mucous 
and serous membranes. There are many forms of the disease, giving 
rise to several divisions by authors ; but the best division is that of 
simple, phlegmonous, and cedematous; some have added to this, 
gangrenous. It is all the same disease in degree, and modified by 
peculiar constitutions, habits, etc. 

It is said to be idiopathic or traumatic, according as it is or is not 
developed by injury. 

Most frequent in foul atmospheres, crowded lanes, hospitals, camps, 
etc. 

May occur in any part of the body; the idiopathic type most 
common about face, scalp, neck, or trunk; while the traumatic is 
most common in the extremities. Injuries of scalp, tendons, and 
aponeuroses often give rise to it in bad form. 

Erysipelas sometimes assumes the epidemic type. 

There are strong reasons for believing it to be contagious in its 
aggravated forms ; may certainly be inoculated or communicated to 
a wound by a sponge used in the disease. 

Causes. — Certain articles of diet; derangement of digestive or- 
gans ; intemperance in drinking and eating ; suppressed secretions ; 
bad air ; frequently supervenes on wounds, particularly the lacerated, 
gunshot, poisoned, bites of animals, etc. Some child-bed fevers are 
probably from erysipelas of uterus, uterine veins and appendages. 

Its effects on wounds — prevents adhesions. 
" ulcers, chancres, etc. 

The varieties are as follow : — 

Simple Erysipelas is the term used to designate that form which is 
confined to the skin. 



56 SYLLABUS. 

Symptoms — a bright, almost scarlet, color of the skin; pungent, 
burning pain; feeling of thickening and stiffness, with here and there 
small vesicles filled with serum. There is very little swelling, and 
not much constitutional disturbance, unless it covers a large surface. 
The attack is of short duration usually, and is followed by desquama- 
tion of the skin of the affected part. 

Phlegmonous Erysipelas is a disease of much graver character 
than the simple. There is great constitutional disturbance, and the 
inflammation attacks the subcutaneous tissues, forming extensive ab- 
scesses, sloughs, etc. 

The color is more purple ; there is great swelling ; pain is violent 
and throbbing, with great heaviness, stiffness, and numbness; and 
extensive vesication soon takes place. The abscesses burrow deeply 
and widely, not only destroying extensively the cellular tissue, but 
muscles and tendons. Extensive sloughs sometimes follow, and the 
constitution is worn out with typhoid symptoms and prostration. 

Oedematous Erysipelas. — This variety depends upon the accidental 
complication of serous effusion into the cellular tissue. Most com- 
mon about the eyelids, scrotum, prepuce, vulva, and lower extremities 
of debilitated individuals. There is much swelling, but little pain or 
discoloration; the surface looks glassy, and pits readily. There is 
usually much constitutional disturbance, and gangrene is more apt to 
result than abscess. 

Erratic is a term used to designate that form of erysipelas in which 
the disease travels rapidly, and jumps from one part to another. 

Anatomical Characters of Erysipelas. 

In the milder grades there is simply a slight thickening and en- 
gorgement of the skin, with effusion of serum, in the subcutaneous 
cellular tissue. In the phlegmonous form there is deep-seated and 
ill-conditioned suppuration, with destruction of the cellular tissue, 
and ordinary products of unhealthy inflammation. 

Constitutional Symptoms. — The external disease is preceded by 
malaise, headache, loss of appetite, lassitude, rigors, fevers, etc., for 
some twenty-four or thirty-six hours. The constitutional symptoms 
then all become much aggravated; fever often runs high, of typhoid 
character, and there is great prostration; the tongue becomes dry 
and dark, and delirium is of very common occurrence. In the milder 
forms of the disease there is very little constitutional disturbance. 



ERYSIPELAS. 



5t 



Diagnosis generally easy ; can only be confounded, in its mild form, 
with erythema. 

Treatment. — Being the result of so many causes, and appearing in 
so many different grades and forms, the treatment must necessarily 
vary according to circumstances ; in fact, remedies of the most oppo- 
site character are demanded by different cases. 

Authors tell us much, in the constitutional treatment, about the 
virtues of blood-letting, emetics, purgatives, antimonials, and other 
antiphlogistic treatment ; but I confess that I have made little use of 
these remedies, and however they may be demanded in colder lati- 
tudes, they rarely find a place in the treatment of this disease as it 
presents itself in this part of the world. 

If a case of inflammatory form, where the symptoms should justify 
it, should call for it, we might bleed and give antimonials; an occa- 
sional dose of mercury may be given when the tongue is furred, and 
the liver not acting well ; but this remedy should be cautiously ad- 
ministered, and ptyalism carefully avoided. Gentle purgatives may 
be used when clearly indicated by the state of the bowels. A light 
emetic of ipecac, may be given with advantage when the stomach is 
loaded or foul. The stomach and digestive organs being always an 
important point, if not the real seat of the disease, they must be 
attended to properly without being over-irritated. 

When purgatives are given, a dose of calomel and rhubarb, or blue 
mass followed by oil, will be best. 

Diaphoretics are useful, and particularly Dover's powder, as ano- 
dynes are generally called for in this disease. Nentral mixture, or 
citrate of potash, with a little morphine added, answers well ; tinc- 
ture of aconite in three-drop doses, where there is much heat of skin 
and arterial excitement, may be given with advantage every three or 
four hours. 

Anodynes form a very important class of remedies in the treatment 
of erysipelas — there is, perhaps, no form of disease in which they 
produce such good effects: a pretty full dose of opium, say two 
grains, or half a grain of morphine, about twice in twenty-four hours, 
seems to answer best. 

Even when there is delirium, opiates act well, quieting delirium and 
promoting sleep, as in delirium tremens. 

The morbid action in this disease differs from that of true inflam- 
mation; in those cases where delirium has formed a prominent symp- 
tom, dissection shows no marks of true inflammation in the brain or 
its membranes. 

Stimulants and tonics are often demanded even in the early stages. 



it 



v 



m 



58 SYLLABUS. 

Carbonate of ammonia, quinine, brandy, wine, porter, ale, with broth, 
are to be used when there is a tendency to depression, even with a 
hot and dry skin, dry tongue, and rapid pulse. Milk-punch is a con- 
venient form of stimulant. 

The mineral acids, and muriated tincture of iron are also recom- 
mended, and the latter article particularly, when the stomach will 
bear it, is of late much resorted to, and I think with the best effects, 
in doses of fifteen to twenty-five drops every six hours. By some its 
action is regarded as specific. 

Local Remedies. — Of these an infinite variety have been recom- 
mended, which proves that we have really no one very reliable remedy. 
Where a remedy like quinine is much used by the profession, and ex- 
hibits specific properties, it is soon generally adopted. If it be true, 
as many believe, that the cutaneous eruption is merely an external 
sign of internal or constitutional disorder, our main reliance must be 
placed on internal remedies, and external ones be regarded merely as 
adjuvants. 

Leeching has been recommended, but is applicable to a small pro- 
portion of cases. 

Iodine, in the form of tincture or solution, is one of the most pop- 
ular remedies of the day, and I believe most useful. The tincture, or 
Lugol's solution, diluted with an equal quantity of water, may be 
applied about twice in the twenty-four hours, with a brush or feather, 
over the inflamed surface and on the margin of the sound parts. 

Nitrate of silver, either solid or of the strength of one or two 
drachms to the ounce of water, is preferred by many, acts much in the 
same way, and I think is about of equal virtue. Like iodine, it should 
be applied over the diseased and surrounding sound skin. 

Pure creosote, strong solution of sulphate of iron, lead-water, 
chloride of soda, British oil, (which is a favorite remedy with Pro- 
fessor Gibson,) and many other astringent and stimulating articles 
have been recommended. 

Mercurial ointment has been much used by some, but is certain to 
salivate when applied about the face. 

In slight cases, dusting the part with flour, starch, arrow-root, etc., 
often affords much relief from the itching. 

Where there is much tension or suppuration, free incisions give 
much relief — it is a remedy not to be neglected. When the swelling 
is from serum alone, a number of small punctures with a lancet will 
answer well. A bandage smoothly applied often gives much comfort. 



FURUNCLE, OR BOIL — ANTHRAX, OR CARBUNCLE. 



59 



FURUNCLE, OR BOIL. 

This is an inflammation of peculiar character of the skin and sub- 
cutaneous cellular tissue. 

Cause, unknown, but generally connected with some peculiar state 
of the system or blood. The inflammation results in suppuration 
and sloughing of the involved cellular tissue. Boils are so common, 
that it is useless to give a minute description of the symptoms, etc. 
They take from three to eight days to ripen. When mature, they 
discharge a core, which is the slough of cellular tissue. 

Where there is a tendency for many to form at the same time or 
in succession, it becomes necessary to attend to the condition of the 
system. A mercurial purge or two ; attention to the diet, and the 
use of sarsaparilla and iodide of potash, will be found the best general 
course; in warm weather, I have found the free use of lemonade 
useful. 

Little can be done toward arresting their course after they com- 
mence ; the application of tincture of iodine has been recommended. 
The best treatment usually is repeated hot poultices and an early 
opening by the lancet. 

Where boils occur in a debilitated condition of the system, as after 
typhoid fever, small-pox, etc., tonics, fresh air, good diet, sea-bath- 
ing, etc. must be resorted to. 



ANTHRAX, OR CARBUNCLE. 

This malady is little more than a mammoth boil, being identical 
in anatomical characters, and distinguished mainly by its size and 
disposition to spread. 

It may occur on any part of the body, but is most common on 
posterior part of the trunk, and particularly on nape of neck. Is 
far more frequent in old, and very rare in young subjects ; the intem- 
perate in eating and drinking, and those of gouty or otherwise vitiated 
constitutions, are the most common subjects. The size of carbuncles 
varies from that of a filbert to that of a saucer, the most frequent 
size being about that of the palm of the hand. 

Of the immediate causes we know little, but, like erysipelas, it 
seems to be more a constitutional than local malady. 

Symptoms. — At first there is a little burning point of pain, with 
an erysipelatous-looking spot of redness, with hardness and tender- 
ness. The pain soon becomes greatly aggravated, with much throb- 
bing, and a sense of burning heat as if in contact with heated metal. 






60 SYLLABUS. 

The swelling extends around and beneath, and becomes exceedingly 
tender to the touch ; the part becomes very hard, as if the skin and 
parts below were hardened and glued together ; the surface becomes 
of a dirty, congested red, and at its center vesicles form, containing 
a dirty, sanguinolent serum; upon bursting, these vesicles expose 
honey-comb openings in the true skin leading down to the cellular 
tissue, which is in a sloughing condition. These little ulcers dis- 
charge a dirty, ichorous fluid, but no genuine pus. If the part be 
cut into, the skin is dense and hardened ; the dead cellular tissue re- 
sembles a mass of wet tow, bathed in ill-formed pus, with flakes of 
lymph or matter like curds or putty. When the disease is extensive, 
the muscles, tendons, and aponeuroses become involved; there is 
much deposit in the surrounding areolar tissue, rendering it very 
dense. 

The constitution soon sympathizes, and a train of symptoms, re- 
sembling closely those described in erysipelas, appear: rigors, low 
fever, dry, foul tongue, great debility, derangement of digestive 
organs, tendency to delirium, etc. 

When of large size, and particularly when seated on the back of 
neck, in old subjects or those of bad constitution, this disease is full 
of danger. 

Treatment. — It is of first importance that the general system 
should be looked to. Moderate purging is required to cleanse the 
primse vise, after which tonics and good diet are usually called for, 
as quinine, ammonia, brandy, ale, tincture of iron, etc. Anodynes 
too, in full doses, are indispensable to procure relief from pain, and 
sleep. 

Numerous local remedies have been recommended, as iodine, nitrate 
of silver, etc.; but they are of little value, as they do not reach deep 
enough to touch the disease. The best local remedies are hot poul- 
tices and free incisions ; a bold crucial incision should be made across 
the whole extent of the hardness, and down to its very bottom ; in a 
day or two strong caustics may be applied, as vegetable caustic, 
chloride of zinc, acid nitrate of mercury, etc. The dead tissues 
should be cut away as fast as they become partially detached. After 
the sloughs have entirely come away, any simple dressing will an- 
swer ; basilicon ointment, dry lint, etc. 

BED-SORES. 

This, in low types of fever, in fractures, and other conditions where 
the patient is long confined to bed, is a frequent and very trouble- 



BURNS AND SCALDS. 61 

some species of gangrene of the skin. The most common seats are the 
sacrum and trochanters, which have to sustain the most prolonged 
pressure; persons paralyzed by injuries of the spine are peculiarly 
subject to this form of gangrene. 

Patients long confined to bed, and particularly those affected with 
paraplegia, should be carefully watched, as not unfrequently con- 
siderable sloughs form before they are suspected even by the patient. 

The cases are usually preceded by some local symptoms of burn- 
ing, redness, inflammation, etc., like gangrene elsewhere; they differ 
in extent, from very small to very large and deep sloughs, with 
ulceration. 

The old proverb, that "an ounce of prevention is worth a pound 
of cure," is peculiarly applicable here. Much has been said about 
hardening the parts, as a preventive, by the application of tannin, 
alum, iodine, etc.; but the great point is by proper padding to keep 
the pressure of the body off from the part in danger. The parts 
should be kept perfectly clean, and the posture of the patient fre- 
quently changed ; an air or water bed is of great value in such cases, 
where it can be procured, and great relief may be afforded by air- 
cushions and well-adjusted pads of hair or wool. Simple water 
dressings, with the addition of astringents, are the cleanest and best. 

BURNS AND SCALDS. 

These injuries differ from each other simply in one being the pro- 
duct of moist, and the other of dry heat. They are presented to us 
in every possible grade, from a slight blush of the skin to the entire 
destruction of a part. Another important difference is in the ex- 
tent, and these differences influence greatly the prognosis and the 
treatment. 

Many divisions of burns have been made, but the simplest arrange- 
ment is the best, as they merely differ in degree ; that of Dr. Gross 
answers all practical purposes, viz., "the simple and the compli- 
cated ; comprehending under the former term those lesions which, 
however extensive, produce only inflammation, and under the latter, 
those which cause the death of the parts, either on the instant, or 
within a short time after their infliction." 

In the mildest forms of burn there is simply an erysipelatous blush, 
with smarting, stinging pain; the duration may be very short and 
pass off without any visible sign, or, when a little more severe, may 
be followed by desquamation. In neither form is there any consti- 



62 SYLLABUS. 

tutional disturbance, except when a very large surface is involved, 
and even then it is of short duration. 

The application of heat, when more intense, whether dry or moist, 
unless sufficiently powerful to disorganize the part, is followed by 
the development of vesicles filled with serum. When slowly developed, 
they are sometimes filled with a thick albuminous material, like that 
often seen after a fly-blister. These vesicles differ greatly in number 
and size in different cases, according to the intensity of the heat, 
sometimes being very small and scattered, while in other cases large 
masses of cuticle are detached followed by a profuse drainage of 
serum. 

The surface around the vesicles is swollen, very florid, exquisitely 
painful to the touch and even to the air ; the pain is peculiarly pun- 
gent, which is quickly followed by swelling and throbbing ; severe con- 
stitutional symptoms soon arise, proportioned to the gravity of the 
injury and the peculiar temperament of the subject. 

We say that a burn is complicated, when the vitality of the part 
is destroyed, or it is accompanied by fracture, dislocation, or other 
injury. The disorganization may be confined to the skin, or extend 
to all the soft parts beneath. 

The intensity of the burn depends upon the length of time, as well 
as the manner in which the part is exposed, as fire, molten metal, 
boiling oil, soap, hot water, steam, etc. Some fluids contain more 
heat, or are more adhesive than others. 

The constitutional symptoms are generally violent and distress- 
ing. A very superficial burn, when covering a large surface, may 
produce great constitutional disturbance — greater often than a very 
severe burn confined to a small surface ; and you must be careful not 
to make light of an extensive burn, however superficial it may be. 

The immediate shock to the constitution is frequently severe and 
even fatal, reaction not taking place. Besides intense pain, the pulse 
is very rapid and feeble ; nervous system greatly depressed ; surface 
cold, with chilly sensations; nausea and vomiting, with extreme 
anxiety and distress of countenance ; respiration oppressed, etc. 

When reaction takes place fully, there is high fever, with tendency 
to delirium, etc. The brain often suffers greatly, showing on dissec- 
tion inflammation of the meninges; and there is not unfrequently 
diarrhoea with ulceration of the bowels. 

It sometimes happens that there is little fever, even in severe burns, 
for some days or even weeks. 

You have all seen examples of the frightful scars left by burns — 
the consequent unnatural adhesion of parts ; distortion of limbs and 



BURNS AND SCALDS. 



63 



other parts ; stiffness of joints, etc. These scars have a tendency to 
contract long after healing is complete, and to increase the deformity. 

Treatment. — The indications are — 1st. To relieve suffering and 
promote reaction. 2d. To combat inflammation. 3d. To detach the 
sloughs when they occur, as soon as possible, and promote granula- 
tion. 4th. To prevent contraction of cicatrixes and anchylosis of 
joints. 5th. To sustain the powers of the patient, in protracted cases. 

The first indication is best met by a full dose of opium, and, if 
need be, brandy, ammonia, warm applications, sinapisms, etc. Opium 
is borne well, and less than from sixty to one hundred drops of laud- 
anum in an adult will be of little service, or one grain of morphia. 

For the purpose of allaying inflammation and giving relief, an 
infinite variety of remedies have been recommended, and it is not 
only true that no one of them is reliable in every case, but different 
applications seem to suit best different subjects. One is most re- 
lieved by cold, another by warm applications, etc. The main indi- 
cation seems to be, in local applications, to protect the burned sur- 
face from the atmosphere, and to do this by the mildest and most 
agreeable means; hence most of the remedies recommended for re- 
cent burns act on the same principle and fulfill the same indication : 
cotton, flour, molasses, lime-water and linseed oil, cloths wet with 
cold or warm water, and other mild lotions, poultices of various 
kinds, as bread and milk, flaxseed, elm, etc. These applications have 
to be varied frequently as the feelings dictate, and their temperature 
must also be governed by the same rule. 

A favorite remedy with Professor Gross, and one I have used with 
benefit, is the carbonate, or common white-lead paint ; it is softened 
with linseed oil to the consistence of cream, laid on lightly with a 
soft brush, and then covered with cotton and bandage ; if there is not 
much discharge it need not be changed for several days. 

It is well known that many poisonous drugs, as arsenic, mercury, 
morphine, etc., are absorbed into the system and produce their specific 
effects. Fears have been expressed that the carbonate of lead, like 
others applied to raw surfaces, might produce deleterious effects; 
but experience teaches the contrary. Dr. Gross mentions one case 
of a negro with an extensive burn on neck and chest, in which he 
used a quart of the lead in five weeks without any bad effect. It 
would seem to produce its good effects by forming a protective coat- 
ing, and by its soothing, sedative influence; the relief is sometimes 
immediate and decided. 

Where there is incipient gangrene, or the burn has existed some 
time, and a stimulating remedy is wanting, the Kentish ointment, made 






64 SYLLABUS. 

in the proportion of an ounce of basilicon ointment to a drachm of 
oil of turpentine, has enjoyed a high reputation ; or, instead of this, 
the part may be penciled with nitrate of silver, about a scruple to 
the ounce of water. Dilute acid nitrate of mercury, tincture of iron, 
nitric acid, and many other stimulants, meet the same indication of 
rousing the dormant energies of the part ; stimulating poultices or 
water dressings may then be applied. 

During the whole course, the condition of the system must be care- 
fully watched and indications met. 

In order to prevent adhesions, as the fingers and other parts, lint 
should be interposed between the denuded surfaces, and splints should 
be applied. 

In order to prevent the contraction of fingers, arms, legs, etc. dur- 
ing and after the formation of cicatrixes, splints must be kept applied 
even long after the healing is complete. 

Where deformities from contraction do occur, and the cicatrix is 
narrow, we sometimes correct them by dividing them with a bistoury ; 
where they are large, they are sometimes benefited by dissecting them 
out, and placing the neighboring sound skin over the wound and 
making it adhere. If every portion of the modular tissue is not re- 
moved, no benefit will be derived from such operations; the contrac- 
tion will be certain to recur. 

FROST-BITE AND CHILBLAIN. 

From protracted exposure to cold, and particularly if the patient 
approaches too suddenly the fire, symptoms of frost-bite, or the after 
effects of chilblain, are the consequences. 

Where a part, as the toes, fingers, ears, etc., has been exposed to 
cold until almost or quite frozen, if suddenly warmed, mortifica- 
tion is sure to follow ; it is therefore best to rub them with snow or 
pounded ice, immerse them in cold water, use frictions, and restore 
the heat in the most gradual manner possible. But such cases are so 
rare at the South, that they do not demand much of our attention. 

Pernio or chilblain are secondary effects of cold, and differ much 
in degree, from a simple erythema to ill-conditioned ulcers, or even 
gangrene. The slighter forms of chilblain are not uncommon in the 
higher classes of society, and particularly among those of luxurious 
and indolent habits. 

They are usually preceded by slight vesication and burning, tin- 
gling sensations; these symptoms may continue for a considerable 
time, or disappear, returning in a less degree from time to time, and 



SEBACEOUS TUMORS. 



65 



giving a good deal of annoyance ; sudden changes of weather may 
bring on attacks, and the parts become red or purplish, swollen, pain- 
ful, and oedematous; little vesications often occur, with insupport- 
able itching and tingling. 

Ill-conditioned ulcers sometimes occur, involving the fibrous tis- 
sues, and are tedious and difficult to heal. Gangrene is usually a 
primary and not secondary effect of cold, and must be treated on the 
general principles already laid down. 

Treatment of chilblain is often troublesome and unsatisfactory. 
A variety of remedies have been recommended ; those of slightly stim- 
ulating character seem to answer best. In the milder forms immer- 
sion in cold water often affords prompt relief, and afterward applying 
laudanum and water ; alcohol and water, or, what is often best, dilute 
tincture of iodine or solution of nitrate of silver ; sometimes cotton, 
or spirits of camphor give relief. 

There are other forms of affections of the skin which come prop- 
erly under the domain of surgery, among which we shall allude to 
those which you are likely to see. They are 



4 



SEBACEOUS TUMORS. 

These consist of the enlargement of a sebaceous gland or follicle, 
with the retention of its secretions, and have been designated by the 
names encysted, atheromatous, meliceric, steatomatous, and folli- 
cular, and even wen. 

Formed by the closure of the orifice or excretory duct of the 
follicle ; the gradual accumulation of the secretion, and enlargement 
and thickening of the sac ; the size varying from a pea to that of 
an orange. 

The contents are very variable, both in color and consistence; 
generally thick and whitish, resembling lard or tallow; sometimes 
resembling honey, putty, flour and water; and sometimes hairs are 
found in them, and also calculous matter. 

The cyst differs much in thickness; has little vascularity, and its 
development is very slow and unaccompanied by pain. Sometimes, 
when of long standing or irritated, it ulcerates and forms trouble- 
some sores. 

These tumors are more or less globular, and usually very movable. 
They are most common on the face, forehead, and scalp, but are not 
unfrequently seen on the neck, eyelid, shoulder, scrotum, back, or 
buttock. 

The number varies greatly : sometimes solitary ; often five or six, 









66 SYLLABUS. 

and sometimes as many as one or two hundred, scattered over the 
body. 

The diagnosis is generally plain. These tumors are characterized 
by slow growth ; insensibility ; soft, doughy feeling ; spherical form ; 
mobility; subcutaneous position; absence of enlargement of the 
veins ; and normal appearance of the skin. 

Treatment. — The only remedy is excision, and it should be 
thoroughly done ; unless every particle of the cyst is removed, it may 
return. When the tumors are on the scalp, they are very easily re- 
lieved ; a single incision enables the surgeon to turn the whole mass 
out with great facility. In other parts, the best plan is to make an 
incision down through the sac ; turn out the contents ; seize the edge 
of the sac with forceps, and with the point and handle of the scalpel 
turn it out. If the integuments are inflamed or ulcerated, it is often 
best to remove a part by elliptical incisions. 

MOLLUSCOUS TUMORS. 

These are a singular form of tumor, which derive their name from 
their resemblance to the knots on the bark of the maple. When fully 
developed, they are about the size of a ripe currant, with a central 
depression on the surface. They differ in form : some are round or 
oval ; some elongated ; others pedunculated, etc. They are usually 
red, reddish brown, or yellowish ; soft and spongy. 

These tumors occur in various parts of the body, and may exist in 
immense numbers. They are sometimes seen in several members of 
the same family. Most common in adults. 

Their progress is sometimes very rapid, the surface of the body 
being sprinkled over with them in a few weeks. Of the exciting 
causes we know nothing, they being the result of inflammation of 
the sebaceous glands ; the sebaceous matter being secreted too rapidly 
to escape through the natural channels, bursts them open, presenting 
a lobulated appearance. 

When not interfered with, they ulcerate, the contents are discharged, 
and they heal. They sometimes slough, leaving ugly scars. Some- 
times they become atrophied, aud form little wart-like excrescences. 

They may be easily removed by the knife or touching with caus- 
tics; or tincture of iodine is usually sufficient. Cleanliness must 
be preserved, and the general health attended to. 



MOLES — HYPERTROPHY OF THE SKIN — ELEPHANTIASIS. 



6t 



MOLES. 

These are congenital marks occurring on various parts, and usually 
of little importance, except from the disfiguration they cause when 
appearing on the face or other exposed parts ; they are dark, gray, 
brown, or black, and mostly covered with hair. They are generally 
a little elevated above the surface, more or less hard, and varying in 
shape and size — usually not more than three or four lines in width. 

When irritated by friction or otherwise, they sometimes produce 
troublesome ulcers. The best mode of treating is to excise them, 
and draw the edges together to prevent a scar. Sometimes they are 
best removed by a fine ligature. 



HYPERTROPHY OF THE SKIK 

A morbid growth of the skin sometimes takes place on different 
parts of the body, forming projections more or less pendulous. They 
sometimes produce deformity, or inconvenience from their position, 
and the only remedy is excision. 



%\ 



ELEPHANTIASIS. 

This is a hypertrophy of the skin and cellular tissue. It is com- 
mon in the East and in the West Indies, but rather uncommon in 
this country. 

Its most frequent seat is the leg, where it produces a hideous de- 
formity, giving rise to a strong resemblance to the leg of an elephant, 
whence its name. It occurs also on the scrotum, pudendum, and pre- 
puce, which attain a very large size. In the latter situations it some- 
times weighs many pounds — occasionally as many as a hundred. 

Causes. — Of these we are ignorant, and the pathology is equally 
obscure, though there is reason to believe that the lymphatics are the 
seat. 

Dissection. — The epidermis is very much thickened, rough, irregu- 
lar in surface, and firmly adhering. The true skin is thickened, hard, 
whitish, striated, cutting like bacon rind ; often from one-fourth to 
half an inch in thickness ; the papillae are enormously enlarged ; the 
areolar tissue is changed in character, and becomes so infiltrated with 
fibrin as to look like an inelastic fibroid substance. The muscles 
below are pressed upon and wasted, pale, and in a state of fatty de- 
generation. The blood-vessels are much enlarged, and the extirpa- 
tion is attended with profuse hemorrhage. 






68 SYLLABUS. 

Elephantiasis is irregular in its progress, coming on sometimes 
rapidly, at others very slowly, and always without any known cause ; 
sometimes a blow or other injury seems to be the exciting cause ; so 
with cold water, where the patient has been much in the habit of 
standing in it. In the early stage the symptoms are inflammatory, 
the parts being hot, tender, and red; there is also effusion into the 
subcutaneous tissues, with pitting, hardness, and redness of the lym- 
phatic vessels and glands. There is also fever. 

The diagnosis is so clear that it cannot be confounded with any- 
thing else. The chronic march of the disease, the remarkable devel- 
opment and deformity of the part, and the peculiar condition of the 
skin, will prevent it from being confounded with anasarca, the only 
lesion to which it has any resemblance. The disease will continue 
for life, giving little pain, and little inconvenience except from its 
weight, stiffness, etc. 

Treatment. — There is little reliance, I think, to be placed in any- 
thing but the knife, and when in a position to render this justifiable 
it should be resorted to. 

KELOID TUMOR. 

This is an affection of the skin, and has been so called from its 
fancied resemblance to a crab. " It is characterized by the existence 
of hard, semielastic, prominent excrescences of a cylindrical or rounded 
form, more or less discolored, and the seat of an unpleasant, itching 
sensation. Processes, roots, or branches usually extend from them 
into the neighboring parts, the whole looking very much like the 
cicatrix of a burn." 

This is not a common affection ; occurs at all ages, and, from my 
observation, is far more frequent in blacks than whites. 

It sometimes comes on without provocation, and appears on various 
parts of the body; most generally it is the result of some local in- 
jury — of a wound, scratch, blow, etc., and in negroes it is often seen 
on the back as the result of the lash. The most common causes are 
burns and scalds. 

These tumors vary greatly in size and shape. You see them from 
the size of a flattened pea up to that of a sausage, oblong, round, 
running into every conceivable irregular form — some resembling the 
irregular appearance of a crab, from which the name is taken : they 
are elevated above the skin from one-quarter of an inch to two 
inches, and the surface is wrinkled or puckered. 

These tumors are usually hard, almost cartilaginous to the touch, 






ELOID TUMOR — LEPOID. 69 

generally lighter than the healthy skin, and are devoid of sensibility. 
They are movable, being raised up easily with the surrounding skin. 

The disease is attended by no danger, and has no tendency to de- 
generate into malignant form. 

Dissection. — They are of fibro-plastic structure ; the fibres inter- 
sect each other in every direction, inclosing spaces filled by soft plastic 
matter, which, when cut, to the naked eye presents a homogeneous ap- 
pearance, whitish, and not unlike an unripe pear or turnip ; it creaks 
under the knife like fibro-cartilage ; its internal structure shows little 
vascularity. 

Treatment. — There is no remedy for it. All sorts of remedies 
have been tried without avail, and the knife is worse than useless, as 
the disease invariably returns after extirpation. 

ELOID TUMOR. 

This form of disease is extremely rare. Dr. Warren, of Boston, 
first described it, and gave it the above name, from its coil-like appear- 
ance. It is developed from the skin like the keloid, and is sometimes 
thrown up into coils like an inflated intestine. Like keloid, there is 
no known remedy. 

LEPOID. 

This is a superficial formation, seen most frequently on the face, 
nose, or forehead of elderly male persons of delicate, florid com- 
plexion and light or red hair; sometimes single, but often occupying 
several points at the same time. 

Symptoms. — It generally appears in the form of a small, circum- 
scribed speck not larger than a mustard-seed, of a dirty grayish 
color, which becomes covered with a rough, brownish or greenish 
crust or scale resembling the bark of a tree, whence its name ; if this 
be removed, or fall off, another soon forms ; there is discharged a thin 
fluid which dries rapidly and forms the crust. The disease generally 
continues in this way for years with little increase, if left alone and 
not irritated. 

Sometimes after long duration -in this dormant state ulceration 
takes place, and the skin presents a red, glassy surface, spicular, 
pitted or granular, discharging thin, ill-formed pus. On examination, 
the skin is found to be of a gristly hardness i and much changed in 
texture. There is little pain, but troublesome itching. 

Lepoid would seem to be closely allied in nature to lupus, or epi- ' 
thelioma, as when it degenerates and takes on an active form it pur- 
sues very much the same course, becoming decidedly malignant. 

6 



10 SYLLABUS. 

Treatment. — All treatment being unsatisfactory, the most prudent 
plan, as long as it is dormant and giving little trouble, is to let it 
alone. All irritating remedies, caustics, etc., should be avoided, and 
only a little mild ointment applied to render it soft and comfortable. 
If it is disposed to spread, we may then resort to destructive caustics 
or the knife. 

LUPUS. 

Two forms of this disease have been described, viz., the non-exe- 
dent, stationary or serpiginous ulcer, and the exedent or corroding 
ulcer ; the latter is called the cancroid or voracious ulcer, and was 
formerly known by the name of noli me tangere, from its extreme 
sensibility. Lupus is the Latin word for wolf. The two forms in 
in fact only differ in degree. 

We can say nothing satisfactory about the causes. 

Lupus may occur on any part of the body, but is far more common 
on nose, cheeks, and eyelids, especially the lower ; rarely occurs be- 
fore the age of forty; often breaks out on several points about the 
face at the same time. 

These ulcers are exceedingly unmanageable, and when healed at 
one point break out at another. The discharges are of an ichorous 
nature, and the surface is covered by a brownish, characteristic scab. 
If a part heals, the new skin is hard, white, irregular, pitted, and 
prone to take on disease from slight provocation. The milder form, 
non-exedent, often described as the serpiginous ulcer of the face, 
generally begins either as a small, hard, white, shining tubercle, or as 
a fissure, crack or excoriation, with indurated edges and a thin, 
brownish incrustation; it soon spreads superficially, showing little 
tendency in the early stage to burrow beneath the skin, or even far 
into it." It is essentially a superficial ulcer, except when it attacks 
the nose, where its ravages are often terrific. When seated on the 
eyelids, it pometimes puts on this destructive form. The parts around 
the ulcer are hard, puckered, and tender, generally reddish, though 
not uniformly so. There is darting pain, and itching more disagree- 
able than the pain. 

When the dark scab drops off, another soon forms ; the surface is 
covered by florid, very sensitive granulations, and dirty pus; the 
edges are usually elevated and irregular ; as the ulcer heals on one 
side it spreads on the other, leaving an ugly, burn-like scar. 

Treatment. — None but soothing remedies should be used in this 
variety. The scab should not be removed, but when it drops off, an 
ointment of one drachm of iodide of potash to the ounce of cerate, 



LUPUS. Tl 

the white-lead ointment, or weak red precipitate ointment should be 
applied. Touching occasionally with a weak solution of iodine will 
often be found useful, as will a weak solution of nitrate of silver. 
A watery solution of opium or of morphine may be applied on lint 
when there is pain. 

The general health should be attended to, and I have found decided 
benefit from ten to fifteen drops, three times a day, of a mixture of 
equal parts of Lugol's solution and Fowler's solution of arsenic. 

I will here take occasion to call your attention to a formula of 
arsenic and iodine I am in the habit of using a great deal, which you 
will find useful, convenient, and easily made : — 

B. — Iodine, one scruple ; 

Iodide of potash, two scruples ; 

Water, one ounce ; 

Fowler's solution, one ounce. 

Dose, ten to fifteen drops, in water, three times a day, on an empty 
stomach, an hour before breakfast and dinner, and at bedtime. 

Lupus exedent, or the more aggravated form of this affection, 
should clearly be classed with epithelioma, or the cancroid form of 
disease, and is truly malignant or cancerous in its nature. It com- 
mences in a wart, tubercle, or crack; ulcerates, travels rapidly, and 
commits frightful ravages in a comparatively short time, extending 
not only superficially, but deeply into the subcutaneous tissues. The 
nose, lip, cheek, eye, etc., may be destroyed in a very short time. It 
sometimes, though rarely, becomes arrested in its course, and assumes 
a chronic form. 

The ulcer has a worm-eaten or dug-out appearance, with ragged, 
everted, or overhanging edges ; the surface is covered with unhealthy 
granulations, which discharge foul, ichorous matter; the surface 
around is tender, inflamed, hard, and oedematous. The pain is of a 
sharp, burning, lancinating, and very annoying character. The gen- 
eral health becomes much deranged; the strength and appetite much 
impaired ; loss of sleep, and the patient gradually wears out and dies. 

Treatment. — This is very unsatisfactory. The indication is, if 
possible, to destroy the diseased tissues. The knife has been fairly 
tried and with unsatisfactory result, and it is in this form of cancer 
that escharotics seem to answer best, and are the remedies by which 
quacks occasionally perform striking cures and make their reputa- 
tion Chloride of zinc, the Vienna paste, acid nitrate of mercury, 
the actual cautery, etc. have all been highly extolled. I should pre- 
fer the zinc applied with equal parts of flour, or other inert powder, 






12 SYLLABUS. 

and allowed to stay several hours so as to produce a decided slough, 
and then follow it with poultices, mild ointments, and other simple 
dressings. 

MELANOSIS. 

This disease rarely attacks the skin, and probably never except by 
extension from the deeper tissues; it is a malignant form of disease, 
and little under the control of the knife or other remedies. 

SCIKRHUS. 

This is also a rare form of cutaneous disease. It most frequently 
commences in a whitish spot, a little elevated above the surface, but 
sometimes depressed; of very dense consistence, rough, firmly im- 
bedded in the skin, at first movable, but soon becoming adherent to 
the tissues below. Blood-vessels are seen coursing over and around 
it ; if cut into, it is seen to be composed of hard, fibrous bands, with 
a milky fluid in the interstices. 

The progress is at first slow, but after a time an ulcer is formed 
which is irregular, jagged, foul, painful, burning, lancinating, and in 
every way characteristic of carcinoma ; other spots frequently appear 
in the vicinity, or at a distance from the original seat. The disease 
marches steadily on till the patient is worn out and dies. 

Sometimes the disease commences in the form of a spongy, straw- 
berry-looking wart or excrescence, which bleeds readily. They occur 
successively on various parts of the body. I saw a very distressing 
case in the person of an English gentleman, Mr. Forbes, who had 
settled as a planter on the Alabama River. A small tumor of the 
kind described occurred on the middle of the inside of the arm, and, 
after remaining for two or three years, commenced giving a great 
deal of pain, and bleeding on the slightest touch. The integuments 
being soft and natural around its base I removed it, with a good por- 
tion of skin ; it returned, with others on different parts of the body, 
and he died in about six months, after dreadful suffering. This case, 
as they sometimes do, put on more the character of fungoid tumor, 
or encephaloid, than true scirrhus. 

The knife, or destructive caustics, in the early stage, afford the 
only chance of relief, and it is doubtful whether in genuine cases 
even these are ever successful. 



WARTS — MUSCLES, TENDONS, ETC. 



WARTS. 



muscle. 



ifiC 



These are the little excrescences so commonly seen upon the hands 
and faces of young persons. They consist in a hypertrophied con- 
dition of the papillary and epithelial structure of the skin. We can 
assign no cause for them. 

They are generally conical, with broad base, though sometimes 
attached by a narrow pedicle. The surface is rough, fissured, and 
tuberculated, and they bleed when cut. Those about the face some- 
times degenerate into carcinoma. 

Treatment. — They often disappear spontaneously, and are gener- 
ally easily removed by strong caustic applications. The best local 
remedy is the chromic acid applied to the surface ; they turn black, 
and drop off in six or eight days. Tincture of iodine, pure acetic 
acid, nitric acid, or the bichloride of mercury, also answer well. 

MUSCLES, TENDONS, SYNOVIAL BTJRS^E, AND 
APONEUROSES. 

These are so intimately connected in function and structure, that 
their injuries and diseases may be very naturally grouped together 
for consideration. 

Muscles. 

Muscles are liable to wounds and lacerations, inflammation, atrophy, 
hypertrophy, different transformations, and especially fatty degenera- 
tion. 

Wounds of muscles are remarkable for the retraction of the fibres, 
it being in proportion to the length of the muscle, the separation of 
the divided surfaces sometimes being as much as two or three inches. 
This is an important practical fact, as all available means, such as 
position, bandaging, etc., must be resorted to, to bring the parts as 
nearly as possible in apposition. The union is by ligament, and not 






Laceration of muscles not unfrequently takes place from violent 
muscular efforts, in leaping, dancing, etc. The rupture is most apt 
to occur at the point of union of the muscular fibres with the ten- 
don. ' 

Symptoms. — There is usually a snap or sensation of rupture felt 
by the patient, with sudden inability to move the part; sharp pain, 
ecchymosis, vacuity at the point of rupture, and the patient often 
falls. 



14 SYLLABUS. 

Treatment. — This must vary greatly in different cases. "When the 
ruptured muscle is superficial and its function is important, it is some- 
times best to cut down on it and bring the edges together with sutures. 
Proper relaxed position should be insisted on, and bandages and 
splints applied ; one roller should be applied from below upward, and 
another from above down, meeting at the wound. 

Inflammation may attack muscles like other tissues, but the treat- 
ment has nothing peculiar. 

Fatty transformation is common, and usually the result of chronic 
inflammation, alone or aided by inactivity. The fibres become pale, 
yellowish, whitish, or a pinkish hue, greasy to the touch, and so soft 
as to be broken or torn readily by the fingers. Pressure forces out a 
clear, oily substance ; this oily matter is not deposited simply between 
the fibres, but they are transformed into it. 

Ulceration. — Muscles are little liable to the ulcerative process. 
Phagedenic or other corroding forms of ulceration do sometimes in- 
vade them. 

Contraction of muscles, producing more or less deformity, is not 
an uncommon result of inflammation from cold, gout, rheumatism, 
wounds, etc. 

Treatment. — The cause and nature of the inflammation, as gout, 
scrofula, etc., should be looked to and met with proper remedies. 
Frictions, etc. must be applied, and, when it can be borne, extension 
by proper apparatus resorted to, and, if necessary, division of the 
tendons. 

Atrophy of muscles is not uncommon. 

Causes are inflammation, palsy, defective circulation, inaction. 
Treatment. — -The cause must be first looked to and combated. 
Frictions ; cold douche ; exercise of the muscle ; electricity, etc. 

Tumors. — Hydatids, tumors of almost all kinds, simple and malig- 
nant, may be developed in and around muscles, and require no special 
mention here, as they are treated of elsewhere. 

Tendons. 

Tendons, when divided subcutaneously and excluded from the 
air, unite by plastic matter very readily, and with little inflam- 
mation. When a tendon is divided, the muscle retracts, sometimes 



TENDONS. 75 

an inch or two, and the whole space is filled with fibrin, which grad- 
ually becomes organized and unites the extremities firmly together. 

When a tendon is divided by a cut or wound communicating freely 
with the atmosphere, union does not take place as in the above case, 
but the wound suppurates, granulates, and the space, like any other 
ulcer, is filled up with newly-formed tissue, and the extremities of the 
tendons become firmly adherent to the parts they are in contact with. 

Treatment. — Where the wound is subcutaneous, a piece of adhe- 
sive plaster, to exclude air, rest and position, are all that is re- 
quired. Where the wound is open, the ends of the tendon should 
be brought together with a silver suture, the wound closed, and treated 
by rest, position, water dressings, etc., like any other wound. 

Ruptures resemble in symptoms, and require the same general 
treatment as wounds of tendons. 

Dislocations and hypertrophy of tendons are also sometimes met 
with. 



Thecitis, or inflammation of the sheaths of tendons, is a frequent 
and troublesome affection; it may be the result of cold, gouty or 
rheumatic inflammation, syphilis, sprain, blow, puncture or other 
injury. It may be acute or chronic. It is tedious in its course, 
giving much trouble, and is difficult to manage. 

The most common sites are the sheaths of the tendons of the fin- 
gers, wrist, feet, elbow, ankles, and knee ; and it may occur alone or 
in connection with inflammation of the bursa? or joints. About the 
fingers and hand particularly, it is not only inclined to travel along 
the sheath of tendons, but to attack the periosteum and joints, giving 
rise to intense inflammation and suffering, and is followed by great 
contraction and deformity. 

Treatment. — This should be prompt and strictly antiphlogistic in 
the early stage ; leeches may be applied ; cold water or lead-water, 
or tincture of iodine. These are among the best local remedies ; and 
the part should be elevated. Antimonials, purgatives, opiates, etc., 
should be employed, and any specific taint, as gout, rheumatism, etc., 
should be looked to. 

Ganglion. — This is a small rounded cyst, situated on a tendon to 
which it is firmly bound. It is composed of a sac more or less 
firm, and filled with a white-of-egg-looking fluid. They vary in size 
from a pea to a pigeon's egg. In some cases of long standing, the 
contents are almost solid ; small masses of organized lymph are some- 
times found floating within. 



% 



t6 SYLLABUS. 

There is no discoloration of skin, tenderness or inflammation ; they 
are globular, ovoidal, movable, and elastic. They produce some stiff- 
ness and impediment in the motion of the tendon. These tumors are 
more usual in females, and are seen most frequently on the back of 
the hand and wrist. 

These tumors are most common in hard-working people; and I 
have met them more often in washerwomen than others. It is a ques- 
tion how the cyst is formed, but I am inclined to think that it is sim- 
ply a sacculated expansion of the sheath of the tendon; sometimes 
it communicates clearly with the sheath, while at others the connec- 
tion is closed and the cyst distinct. 

Treatment. — The ganglion is best managed by rupturing the sac, 
allowing the contents to be diffused in the tissues around, and then 
applying a small, hard compress with a bandage. The sac in recent 
cases may be sometimes ruptured by firm pressure with the thumbs ; 
if this fails, the hand may be laid flat on a table and the tumor struck 
smartly with the back of a book. I have often succeeded well by 
dividing the sac freely subcutaneously with a very narrow knife, and 
then applying the compress. Excision or free incisions are improper, 
as the inflammation and adhesions caused may impair the functions 
of the part. 

Synovial Burs^3. 

These are sacs resembling very much ganglia. They are also called 
bursae mucosae, or mucous pouches, and exist in various parts of the 
body as semitransparent sacs filled with a thin, unctuous fluid, and 
most frequently about the joints of the extremities. They are for 
the most part interposed between bone and tendon, between tendons, 
bone, and skin, or tendon and skin, their use being to facilitate mo- 
tion and to protect against pressure. They are most conspicuous in 
those situations subjected habitually to friction. They are sometimes 
developed in unnatural positions, as from the pressure of a shoe, 
crutch, artificial limb, etc.; they are very common on club feet. It 
is estimated that there are about one hundred and fifty of these sacs 
naturally existing in the normal condition of the body, many of whieh 
may be developed into disease. 

"The largest and most important synovial pouches, surgically con- 
sidered, are situated on the acromion process, the space between the 
hyoid bone and thyroid cartilage, the condyles of the humerus, the 
olecranon process, the styloid projections of the ulna and radius, the 
tuberosity of the ischium, the great trochanter, the anterior superior 
spine of the ilium, the front of the patella, the condyles of the femur, 



SYNOVIAL BURS^E. T7 

the tuberosity of the tibia, the ankle, the calcaneurn, and the heads of 
the first and fifth metatarsal bones at their palmar aspect." 

Bursa? are subject to inflammation, suppuration, induration, and 
thickening, dropsical accumulations, and the development of fibro- 
cartilaginous concretions in their interior. The inflammation may be 
either acute or chronic, the latter being the most frequent. Pressure 
and friction are the causes most common; also occasionally blows, 
contusions, wounds, punctures, and gout, rheumatism, syphilis, are 
strong predisposing causes. The housemaid's knee, collier's elbow, 
and bunion on the great toe are good examples of this affection. 

Acute inflammation is not common, but severe when it does occur; 
there is much swelling, great tenderness, tendency to unhealthy, ery- 
sipelatous inflammation, oedema, etc., and not unfrequently there is 
much constitutional disturbance. "When opened, instead of the limpid 
fluid seen in health, the contents are turbid, sometimes bloody, with 
floating shreds of lymph. Sometimes suppuration and ulceration 
tion take place, giving much trouble. 

Treatment. — This should be strictly antiphlogistic : leeches, cold, 
saturnine applications, emollient poultices, etc., with attention to the 
system ; if suppuration takes place, a free opening should be made, a 
tent introduced, and poultices applied. In the mild forms, the tinc- 
ture of iodine, or a blister answers a good purpose. 

Chronic Inflammation. — This form of disease in the bursas is often 
of very long duration, and produces very marked changes in the 
structure of the parts; the secretion becomes changed, the sac 
enormously thickened, with adventitious bands passing through it 
in every direction ; the character of the sac becomes totally changed, 
the cavity very small, the surface rough and granular. The only 
remedy to be relied on is excision, which must be practiced with 
great caution in the neighborhood of joints. 

There is sometimes a true dropsical collection in these bursas, com- 
ing on slowly without apparent inflammation, tenderness, etc.; the 
housemaid's knee, which sometimes contains six or eight ounces of 
limpid fluid, is a good example of this form of affection. In other 
places the size may reach that of a foetal head, and the shape is 
irregular. 

Treatment. — In the early stages they may be often relieved by the 
application of iodine, combined with bandaging. Blisters are, per- 
haps, the most reliable of all remedies; rest is also important. 
When the disease resists these remedies, we resort to the same treat- 
ment as in hydrocele, viz., puncturing with a trocar, and injecting the 



M 



i 



78 SYLLABUS. 

sac with a drachm or two of iodine, diluted, oj: some other stimulat- 
ing fluid. The seton also may be resorted to and kept in for a few 
days, till sufficient inflammation is produced. Occasionally we find 
in these bursse, loose concretions, of fibrous or cartilaginous consist- 
ence, giving a good deal of trouble ; they are irregular in shape, but 
generally resemble melon-seeds. They seem to be formed through 
the deposition of lymph from the surface of the sac, and detached by 
motion and friction. Sometimes bodies like small hydatids are also 
seen ; they are both cured by incision, removal, and tent. 

Aponeuroses 

Are rarely the primary seats of disease, but play often a very 
important part, from being involved in the diseases of neighboring 
tissues. Gout, rheumatism, carbuncle, whitlow, inflammation from 
punctured and other wounds, sometimes implicate or are much in- 
fluenced in their course by the aponeuroses. 

Chronic inflammation in these structures is more common than 
the acute, and leads to various changes of structure, as thickening, 
induration, atrophy, ossification, etc. 

Treatment to be conducted on the general principles of inflamma- 
tion ; when suppuration forms beneath, free incisions are important. 



LYMPHATICS— VESSELS AND GANGLIONS. 

The diseases of this system are obscure, and we have much to learn 
as to the manner in which they become diseased, the part they play 
in the transportation of disease from one point to another; and the 
symptoms by which their diseases manifest themselves; erysipelas, 
elephantiasis, and other affections have been supposed to depend on 
the lymphatics, but it cannot as yet be demonstrated. 

LYMPHATIC YESSELS. 

Angeioleucitis is the name which has been given to inflamma- 
tion of these vessels, and sometimes that of lymphatitis. Its symp- 
toms have been best studied in those cases arising from punctured or 
poisoned wounds, and other injuries. It is also seen as a conse- 
quence of skin diseases, and sometimes appears in the idiopathic form 
without any tangible cause. 

When it arises from a wound, poisoned or not, about the hand, the 



LYMPHATIC VESSELS. 12 

affected vessels may b.e traced beneath the skin in their course, as 
small, reddish cords, tense, nodulated, and painful to the touch, ac- 
companying the principal veins and extending to the nearest gan- 
glions, in which they seem to terminate. Sometimes only two or 
three of these cords are seen, while at others ten or a dozen are pre- 
sented, forming a sort of net-work along their course. When there 
are many implicated there is swelling, with pitting and a good deal 
of tenderness and stiffness. 

In those cases arising from the absorption of morbid poisons, the 
symptoms are much more marked; the swelling is great, extending 
over the entire limb, and the redness instead of being confined to 
lines, is diffused and puts on all the appearances of severe erysipelas. 
In some cases the deeper seated lymphatics become first affected, 
and a good deal of swelling, hardness, etc., may occur before the 
superficial vessels are implicated. 

The lymphatic ganglions nearly always become enlarged and in- 
flamed ; occasionally the first symptoms are manifested in these glands. 

The symptoms of angeioleucitis are declared from the beginning 
by constitutional disturbance, with depression, etc. In twelve or 
twenty-four hours after the injury, the patient feels chilly sensations, 
accompanied by flushes of heat, pain in different parts of the body 
and head, dry skin, etc. Sometimes the chill is severe, and followed 
at once by delirium and high fever, which soon assumes the typhoid 
form. The local symptoms become rapidly aggravated; the swell- 
ing is great, and foul abscesses are formed along the limb, the matter 
burrowing, like in phlegmonous erysipelas, extensively among the 
tissues. 

Diagnosis. — This is not always easy; angeioleucitis may be con- 
founded with erysipelas and phlebitis. The distinction can only be 
well made in the early stage when the inflamed lymphatics can be 
seen coursing along to terminate in the ganglions. In phlebitis, 
similar red lines are seen, but the cords are much larger, firmer, and 
more knotty, and deeply seated ; they are also less numerous and in- 
volve less the glands. Erysipelas usually begins as a circumscribed 
superficial skin affection, without the striated appearance of the other 
affections. 

Treatment. — This affection, as stated, resembles much erysipelas, 
and must be treated on the same general principles recommended in 
this and phlebitis. The exciting cause should first be removed, and 
the local symptoms met as they present themselves, bearing in mind 
that the disease is essentially typhoid in its tendency, and that anti- 
phlogistics are badly borne. Leeches along the course of the in- 



% 



80 SYLLABUS. 

flamed vessels have been much lauded ; but, to say the least, their 
efficacy is doubtful, as the bites are prone to produce erysipelatous 
inflammation in such conditions of the system. Iodine may be 
applied with benefit, and either warm or cold applications, as most 
agreeable to the patient. Hop or poppy fomentations give much 
relief, and strips of blistering ointment along the track of the in- 
flamed vessels have been highly recommended. When matter forms 
it should be early evacuated. 

Quinine, tincture of iron, brandy, ammonia, must be used as symp- 
toms indicate; anodynes also are indispensable. 

A varicose enlargement of the lymphatics has been described by 
Carswell and others ; but it is of very rare occurrence. 

LYMPHATIC GLANDS. 

These are very common seats of disease, from various causes. They 
are very liable to inflammation, chronic enlargement from scrofula, 
and other causes ; degeneration and tumors of various kinds. 

Adenitis, or inflammation of these glands, may be acute or chronic, 
and is of very frequent occurrence. It is most usual in young 
subjects of strumous diathesis, and is excited by cold or local irrita- 
tion affecting the lymphatic vessels. The inflammation may be com- 
mon or specific, as that from syphilis, scrofula, dissection wounds, etc. 

Acute adenitis is most generally seen in the glands of the neck, 
jaw, supra-clavicular region, groin, and axilla. One, several, or many 
glands may be affected at the same time, and the disease is rarely 
limited to one or two. It commences as a hard, tender knot, and 
increases in size with great rapidity, though varying from that of a pea 
to an egg. The increase is sometimes very quick, the size of a filbert 
being attained in a few hours ; the cellular tissue around is implicated, 
the skin becomes inflamed, and the parts adjacent pit on pressure. 
The inflammation frequently puts on an erysipelatous appearance, 
and the constitution sympathizes. 

Adenitis may end by resolution, suppurate, or become chronic. It 
sometimes vanishes in a few hours. Gentle friction with liniments, 
warm drinks, foot baths, etc., will sometimes, though rarely, remove 
it. In the severer cases, purgatives, diaphoretics, tartar emetic, etc. 
become necessary, with antiphlogistic regimen. Leeches, and the 
tincture of iodine, are often useful. 

When suppuration takes place, which it does in from a week to 



LYMPHATIC GLANDS. 81 

ten days, it does not confine itself to the glands, but involves the are- 
olar tissue around. The abscess should be opened early, and followed 
by poultices. 

Chronic Adenitis is of very frequent occurrence, either as the 
sequel of the acute form, or otherwise. It is sometimes very slow in 
its course, changing entirely the structure of the glands ; when cut 
into, it presents the marks of the inflammatory process. The color 
is various, according to the degree of vascularity and character of 
the deposits: sometimes they are enlarged and much indurated, and 
at others softened. Sometimes it cuts, and looks like a green pear or 
turnip. The hardness is occasionally so great as to resemble scir- 
rhus, and frequently the gland is enveloped in a capsule formed of 
condensed cellular tissue. A single gland may attain considerable 
size, but usually a number are agglomerated together, forming a 
nodulated mass, sometimes attaining the size of an orange. 

These hypertrophied glands may occur in any part of the body, 
but are generally seen in some part of the neck. They are also seen 
in the cavities, as the chest, about the root of the lungs, the mesen- 
tery, pelvis, etc. ; interferes with respiration, assimilation, parturition, 
etc., by pressure from their position and size. 

A variety of causes give rise to enlargement of these glands, some 
of which are constitutional, others local. About the neck they may 
arise from cold, or disease of jaw, gum, tonsil, or other local irrita- 
tion ; in the groin, from ulceration of the penis ; in the axilla, from 
affections of the mamma, or injuries about the hand or arm ; in the 
mesentery, from irritation of the small intestines, etc. A strumous 
state of the system, however, is the most prolific cause. 

This chronic enlargement is always more or less obstinate, and 
often continuous for years. 

Treatment. — This is both local and constitutional. The exciting 
cause, when discovered, should first be removed; a carious tooth; 
ulcer on the penis must be removed before the effect can be got rid 
of. The general health is much concerned, and must be attended 
to. Sometimes the antiphlogistic treatment may be at first required, 
but rarely. Commonly the opposite course is demanded, as good, 
nourishing diet, quinine, iron, cod-liver oil, pure air and exercise, to- 
gether with the specific, alterative effect of iodine; smart purging, 
when the tongue is foul, often facilitates the^cure much. 

The local remedies are discutient liniments, and particularly the 
tincture or ointment of iodine, the mercurial plaster, etc. Blisters 
and steady compression are often of great service ; the pressure may 



82 SYLLABUS. 

in many cases be well made by a truss. When other remedies fail, 
and the symptoms demand relief, the glands may sometimes be extir- 
pated by the knife ; but great care should be taken to avoid the im- 
portant anatomical structures around them. 

Scirrhus and encephaloid sometimes attack these glands, and 
soon put on the characteristic appearances they present in other 
parts. 

Tubercular disease of these glands is most commonly met in young 
subjects, and often coexists with tubercular disease in the lungs, joints, 
and other organs. They sometimes undergo earthy degeneration, 
looking like bone, and at others are the seat of fibro-plastic growths, 
for either of which excision is the remedy. 



DISEASES AND INJURIES OF NERVES. 

When divided, nerves are readily united, if in close apposition, by 
plastic matter, which, though not assuming the identical structure of 
the nerve, answers to transmit the nervous current. If, however, the 
retraction be great, or a portion of nerve be removed, the interval is 
supplied by ligamentous matter which does not transmit the current. 

When a nerve is severed, its function is completely arrested for the 
time being, whatever it be. When a nerve of large size is divided, 
considerable time is required for the restoration of its function, and 
it sometimes never regains again its normal action, there being some 
numbness, or confusion of sensation or motion. This probably arises 
from a want of nice apposition in the fibres of the nerve. 

The treatment is much the same as that of other wounds, bearing 
in mind the necessity of bringing the divided ends as nearly in appo- 
sition as possible ; where they are widely separated, they may be 
brought together by a very delicate suture passed through the neu- 
rilemma. 

When nerves are punctured or partially divided, they are apt to 
cause severe pain, spasm, perverted sensation, neuralgia, numbness, 
and derangement of the general health. The proper remedy is di- 
vision of the nerve. This operation is not always successful, and 
occasionally the nerve at the part becomes thickened, and requires 
excision. 

Sometimes, in consequence of contusion, nerves are bruised, be- 
come inflamed, and their functions impaired. 



TETANUS, OR LOCKED- JAW. 83 



TETANUS, OR LOCKED-JAW. 

This is a peculiar condition of the nervous system, characterized by 
violent contraction of the voluntary muscles, with irregular intervals 
of partial relaxation. When the contraction is confined to the mus- 
cles of the lower jaw, closing the mouth firmly, it is termed trismus; 
when the body is bent firmly forward by the action of the abdominal 
muscles, the affection is denominated emprosthotonos ; and opisthot- 
onos, when bent backward by the dorsal muscles. 

It has been very properly divided into traumatic and idiopathic, 
acute and chronic. It is frequent in children within the first ten days 
after birth, and is here termed trismus nascentium. The traumatic 
and infantile forms are common, and the idiopathic rare in our country. 

The causes of traumatic tetanus are various forms of external in- 
jury, as punctured or lacerated wounds, fractures, dislocations, extrac- 
tion of teeth, gunshot wounds, surgical operations, etc. The causes 
are sometimes of the most trivial kind. Injuries on any part may 
produce tetanus, but those of the feet and hands are most likely to 
do so, and the most usual of all are small punctures in the sole of 
the foot from treading on nails. 

Symptoms. — The period of development varies from a few hours 
to several weeks, but generally from four to fourteen days elapse ; 
often occurs after the wound has healed. 

The attack is preceded by malaise, restlessness, stiffness about the 
jaws and neck ; difficulty in protruding the tongue ; uneasiness at the 
epigastrium, and rigidity of the abdominal muscles. These symp- 
toms, at first very faint, become aggravated; the rigidity of the mus- 
cles increases ; the jaw is firmly locked ; there is inability to turn the 
head ; attempts at deglutition excite spasm in the throat and a sense 
of suffocation. The disagreeable sensation in the precordial region 
becomes greatly aggravated, the distress extending back from the 
ensiform cartilage to the spine, and with a feeling of painful constric- 
tion. The muscles of the back and abdomen, and next, those of the 
extremities, become rigidly contracted; the contraction is so great as 
to bend the body like a bow, backward or forward, according to the 
muscles brought in play. The rigidity exists more or less all the 
time, but distinct spasms, sometimes amounting to convulsion, come 
on at irregular intervals of some minutes. The muscles of the face 
are drawn, the eyes sunken, and the whole expression is haggard and 
greatly changed; the respiration is laborious, and any attempt to 



W 



84 SYLLABUS. 

swallow brings on a paroxysm, as does a slight current of air. The 
sufferings of the patient become very great. 

There is usually little tendency to fever, and the pulse rarely goes 
above eighty or ninety in a minute. All the functions are more or 
less disturbed ; bowels constipated ; urine scanty and high colored ; 
skin bathed in a copious, clammy perspiration ; mind usually per- 
fectly clear throughout. 

The above is the common course, but there are occasionally irregu- 
larities seen in the muscular contractions, and other symptoms. I 
have recently seen a case in which the muscles of the jaw were not 
implicated, the patient being able to open his mouth easily at any 
period of the attack. Sometimes, on the contrary, the muscles about 
the mouth and neck are the only ones affected. 

Tetanus bears no resemblance to any other form of disease but 
hydrophobia, and the diagnosis between them is easy. 

The prognosis in traumatic tetanus is extremely unfavorable, death 
occurring generally in from three to six or seven days. Professor 
Gross says, "in an experience of thirty-one years, I have seen but 
two cases where the patient escaped with life, and then after a pro- 
tracted and painful struggle." This assertion surprises me, as I am 
sure I have seen at least a dozen survive it. I had three cases at 
one time under treatment, and all recovered : one from a splinter 
under the finger-nail ; one from the bursting of a varicose vein ; and 
the third was idiopathic. I say this too without having confidence 
in any particular course of treatment. 

The cases which I have seen recover, have been those of chronic 
form, lasting from thirty to fifty days, and the spasms never being 
very violent. 

Pathology. — Of this we know nothing. 

Treatment. — Unsettled and unsatisfactory. 

NEURALGIA. 

This is characterized by an intense pain occurring in some nerve ; 
usually intermitting and irregular in its attacks, and liable to occur 
in any part of the body; generally dependent on some local irrita- 
tion, but sometimes, perhaps, on derangement of the digestive appa- 
ratus, etc. Our object here is to treat the disease in a surgical point 
of view, and not to follow it in all its intricacies, which belong more 
particularly to another chair. 

Causes. — These are many, and of opposite character. The nervous 
temperament is most liable. Cold and damp — in fact, all the causes 



NEURALGIA. 85 

of rheumatism seem % to be productive of neuralgia, and it is some- 
times hereditary. Injuries, mechanical irritation or pressure in any 
form, as by tumors, etc., are frequent causes. 

The most terrible attacks are seen in the trifacial nerve, from dis- 
eases of the teeth or jaw; foreign bodies, as balls, splinters — in 
short, pressure, exposure, or irritation of a nerve in any way, may 
produce the disease. It is occasionally caused by derangement of the 
digestive organs; by worms, etc.; and is a common attendant on 
uterine diseases. Amputations, and other operations where nerves 
are divided, not unfrequently cause it. Malaria is also a well-known 
cause, the disease assuming a distinct intermittent type. 

Symptoms. — The pain assumes every possible grade and form, and 
is often intense beyond description or endurance. Sometimes it is 
confined to a single spot, at others is diffused, or changes locality 
rapidly and frequently ; at one time affecting one branch, and at another 
many. It is important to remark that the seat of the pain is no 
guide as to the true seat of the disease, or its cause. Derangement 
of the digestive organs may produce neuralgia in many parts of the' 
system ; a carious tooth may produce pain in the face, hip, etc. 
Spinal irritation may produce neuralgia in the leg, foot, toes, etc. 
(Case of John B.) 

Pathology of neuralgia is very imperfectly understood. In some 
cases the nerve or neurilemma is found inflamed or thickened, while at 
others no change can be detected. The causes we have already 
spoken of. 

Treatment. — This will depend in a great degree upon the cause, 
which must always be removed if possible : a carious tooth, a tumor 
pressing on a nerve, a cicatrix, etc. may be exciting causes, and the 
disease relieved by removing them ; worms, derangement of stomach, 
malarious influence, are other causes to be kept in mind. Even when 
the exciting cause is removed, the neuralgia still remains, and in an 
intractable form in many cases. 

In fact, there is no one remedy or class of remedies suitable to all 
cases. In those cases arising from malarious influences, quinine, iron, 
and arsenic are the remedies ; in those cases connected with general 
debility and derangement of the nervous system, these and other tonics 
must be relied on. Where the digestive organs are at fault, purga- 
tives, alteratives, and tonics are the remedies. Emetics are sometimes 
very useful. 

The diet also should be strictly attended to. 

After quinine, probably arsenic enjoys the highest reputation of 
any article in this affection. Strychnine, aconite, Indian hemp, have 

7 



86 SYLLABUS. 

also been much recommended, and the preparations of opium are 
indispensable for the relief of pain. 

Among the topical remedies, may be enumerated particularly 
counter-irritants, blisters, leeches, morphia, aconite, stramonium, and 
other narcotics, and hot applications. 

Of the counter-irritants, blisters are best; in mild cases, iodine or 
ammonia is useful ; morphia may be applied on the denude d blister, 
over the seat of pain, with great benefit. The veratria ointment in 
chronic cases sometimes affords great relief. 

The subcutaneous injection of morphine, and other narcotics, has 
lately come into use, and in many cases relieves the sufferer. 

Section or excision of a portion of the nerve has been performed 
with very variable success. Although they often afford temporary 
relief, the pain almost always returns soon or late. 



DISEASES AND WOUNDS OF ARTERIES. 

This is one of the most important classes of affections that can 
attract the attention of the surgeon. Hemorrhage, particularly from 
a wounded artery, is one of those troubles which the surgeon has 
constantly before him ; this is a leading danger which he fears in 
every important operation, and every wound. 

When called to treat a hemorrhage, the first point is to determine 
whether it is arterial or venous. If it be arterial, the blood is of a 
scarlet color, and it is discharged in intermittent jets, corresponding 
with the pulsations of the heart; when it comes from a vein, the 
blood is dark, and flows in a continuous stream. In very small arte- 
ries the stream is often continuous, and darker, but is thrown out with 
more force than when from a vein. When any artery of any size is 
entirely divided, as in an amputation, the blood will sometimes be 
thrown half across a room. When the vessel is large, the hemor- 
rhage may be fatal in a few seconds or minutes. 

The most common course of profuse hemorrhage, is for the patient 
to become exhausted and faint from the loss of blood, and the action 
of the heart almost entirely arrested, during which condition the 
blood coagulates in and around the extremity of the divided vessel 
or vessels. After a time the patient reacts ; the action of the heart 
becomes stronger; the column of blood is driven against these slight 
barriers ; and, when the vessels are large, the clots are driven out of 
the way, the hemorrhage recurs, and the patient, after one or two 
more of these recurrences, becomes exhausted, and sinks. 



WOUNDS OP ARTERIES. 87 



WOUNDS OF ARTERIES. 



Wounds of arteries maybe incised, punctured, lacerated, contused, 
or gunshot. These wounds may be large or small, transverse, ob- 
lique, or longitudinal, or the artery may be partially or entirely 
divided. 

When an artery is completely divided, there is rapid and copious 
flow of blood, followed by retraction and contraction of each end ; 
the effect of this double action is to diminish the flow, but not to 
arrest it, except in very small vessels. The flow continues usually 
until a coagulum has formed in and around the orifice, in the cellular 
tissue, and particularly in the loose sheath. The flow in this way is 
impeded, but the final arrest is greatly aided by a coagulum forming 
within the vessel and extending as high up as the first collateral 
branch. 

The clots, of which the first bears the name of external, and the 
other that of internal, are the means which nature employs to arrest 
the hemorrhage, but not generally until after fainting, which is favor- 
able to the coagulation of the blood, and gives time for the forma- 
tion of these external and internal clots. The coagula are at first 
very soft, and easily removed, and it is not until plastic matter is 
effused in and around the vessel, and adhesions form, that their pro- 
tective power against hemorrhage can be relied on. This soon takes 
place, as inflammation is established in a few hours, and the clots, 
vessel, and tissues become more or less firmly united, according to the 
length of time which elapses without disturbance from hemorrhage or 
other cause. The absorbents set to work ; the coloring matter and 
serous portion of the effused blood are removed ; blood-vessels shoot 
out, passing through the plastic deposit, which becomes organized, 
and unites the parts all firmly together. 

The external and internal clots are now firmly blended at the ori- 
fice of the divided vessel, like the cork of a bottle well sealed over. 
The outer coagulum is rough and irregular ; the internal one smooth, 
and conical at its cardiac extremity. The longer the internal coagu- 
lum, the less danger of hemorrhage. The changes are going on for 
two or three months before they are entirely completed ; the clots 
being all wholly absorbed, and the vessel being finally reduced to a 
fibrinous cord as high up as first branch above. 

The foregoing is the process by which nature arrests hemorrhage 
from a divided artery. First, in the exhausted or fainting condition 
from loss of blood, the two clots are formed, the vessel having retracted 



88 SYLLABUS. 

within its sheath, and contracted in caliber; next, by the deposition 
of lymph, and the agglutination and organization of the parts, the 
clots are firmly fixed in situ, and the hemorrhage permanently ar- 
rested. Nature next sets to work to remove what is not required, 
and to consolidate the tissues. The process is very interesting, and 
analogous to that by which fractured bones are united. 

When an artery is only partially divided, whether transversely, 
obliquely, or longitudinally, the efforts of nature are much less effi- 
cient in arresting hemorrhage. The vessel cannot retract within its 
sheath ; it does not contract in caliber ; and while an imperfect exter- 
nal clot is forming, it is much more difficult for an internal one to 
form; when reaction takes place after the fainting fits, there being 
little impediment to the current of blood, the external clot is washed 
out of the way and the hemorrhage returns at intervals, till the 
patient is exhausted. So with plastic matter when deposited, it is 
washed off and adhesions prevented. 

Spontaneous cures do sometimes take place when the wound is 
small, the longitudinal being less dangerous than the oblique, and 
the oblique less so than the transverse wounds in arteries, for obvious 
reasons. Such wounds, when not fatal, are very prone to result in 
aneurism, as is sometimes seen at the bend of the arm, from venesec- 
tion. 

We have already given the reason why contused and lacerated 
wounds bleed less than the incised. 

Nature, as we have seen, makes powerful and well-directed efforts 
toward the arrest of hemorrhage from wounds; but the prudent sur- 
geon should never trust them where his means are available. 

Treatment. — The principal means for arresting hemorrhage are 
the ligature, compression, styptics, and torsion. 

Ligatures. — Different kinds are flax or silk, well waxed ; animal 
ligatures, made of buckskin and other substances ; also, metallic 
ligatures. 

Manner of using the forceps and tenaculum. 

Importance of excluding nerves and veins, and of isolating the 
artery as much as possible. 

Manner of applying and tying ligatures ; importance of dividing 
the internal and middle coats, but at the same time no violence is 
necessary in tightening the ligature ; one end of ligature to be cut off. 

When the coats of the artery are diseased, the small hard ligature 
will often cut through, and we should then resort to a small flat one, 
of narrow braid, or several loose threads, well waxed and spread out. 



WOUNDS OP ARTERIES. 89 

Process by which the ligature permanently closes an artery. When 
the coats of the artery are so softened from inflammation as we some- 
times see them in secondary hemorrhage, it becomes necessary to cut 
down upon the artery above the wound, and ligate it where it is 
sound. Where we tie an artery in its continuity, as in cases of 
aneurism, etc., we use what is called an aneixrismal needle to pass 
the ligature, and care should be taken to separate the artery as little 
as possible from its sheath. 

When an artery is divided in a limb or elsewhere by a wound, it is 
a fundamental principle in surgery that both ends should be tied. If 
the cardiac extremity alone be ligated, anastomosing branches will 
almost surely cause bleeding in the distal extremity. 

The hemorrhage from the distal end is not so active as from the 
other ; not spirting out so much in jets, it is darker and flows more 
like venous hemorrhage, but is none the less dangerous. This end 
of the artery retracts and contracts less than the other, and is less 
capable of forming an efficient clot. 

Period at which the ligature is detached varies according to cir- 
cumstances, viz., the size of the ligature and manner in which it is 
tied ; the state of the artery and the amount of inflammation. A 
small, hard ligature cuts its way through sooner than a large one; a 
sound artery resists longer than a diseased one, and much depends 
upon the artery alone, without other tissues being included in the 
ligature. The time at which the ligature is detached varies from one 
to three weeks, according to the size of the artery, other things being 
equal. There are instances where the ligature has held on for forty 
or fifty days, or more. There are examples where the ligature has 
not come away for many months — in one case thirteen months ; but I 
think it bad surgery to allow it to remain so long. 

After a reasonable time has passed, gentle traction should be 
made on the ligature when the wound is dressed; and I have suc- 
ceeded in detaching it, by attaching an elastic string to it and fixing 
the end with adhesive plaster, so as to make permanent traction. 

Compression is also an important means of arresting hemorrhage ; 
it is applicable in some cases where the ligature cannot be used, and 
is particularly applicable in those cases which the injured artery is 
situated over a bone, as the arteries beneath the scalp, the radial and 
ulnar, etc.; also where the hemorrhage is from a number of small 
arteries, instead of one large one. 

The compression may be temporary, to gain time till other means 
can be used; this may be done with the finger, tourniquet, bandage, 



I 



90 SYLLABUS. 

and compress, etc. In permanent compression, it is continued until 
the vessel is completely obliterated, whatever time may be required. 

Temporary compression is particularly applicable in incised or 
gunshot wounds of the extremities, where the surgeon is obliged to 
act promptly to save life ; it may be applied by the finger, the tour- 
niquet, or compress and bandage over the main trunk of the artery, 
as the femoral, brachial, etc. It should be borne in mind that this 
can only be a temporary resort, as the arrest of the circulation in a 
few hours causes pain and numbness, and if continued too long, re- 
sults in mortification. 

The Spanish windlass, made of a hankerchief and stick, is a good 
temporary resort ; this is also called the field tourniquet. The finger 
applied to the brachial or femoral artery is less uncomfortable, and 
often answers well. 

Permanent compression is sometimes applied directly to the bleed- 
ing surface, as in the operation of lithotomy, wounds of the rectum, 
bleeding of the nose and uterus, in operations on the maxillary sinus, 
and other deep wounds where the ligature cannot be applied. 

There are many objections to this mode of suppressing hemor- 
rhage, the principal of which are the pain, inflammation, and sup- 
puration caused; it should therefore never be employed to arrest 
hemorrhage from a large artery, but is particularly applicable to 
those cases where the bleeding is from a number of small arteries, 
particularly in an exposed cavity or a deep-seated wound. 

The compression in some cases is best performed by a graduated 
compress, made of sponge, cotton, lint, etc. The bleeding surface 
must be well cleansed of blood, etc. before the compress is applied, 
and it should be placed directly in contact with the bleeding vessels. 

After the part is dressed, absolute rest and elevated position are 
all-important. The dressings should not be disturbed for four or 
five days if they are well borne. 

Indirect pressure is made by placing the compress on the track of 
the artery above the wound, and is often the surest plan. The best 
way is to apply a narrow compress, two or three inches long, on the 
track of the artery, fixing it firmly with a roller, commencing at the 
distal extremity of the limb, so as to form an equal support through- 
out. This answers well in wounds of the brachial artery at the bend 
of the arm. 

Styptics are those local remedies which arrest hemorrhage by their 
direct action on the blood and its bleeding vessels. There are an 
infinite variety, including astringents, caustics, etc. 

Of the astringents, alum, perchloride of iron, tannin, and sulphate 



WOUNDS OP ARTERIES. 91 

of copper, are the most potent and most employed. The bleeding 
surface should be well cleansed of blood, and the styptic applied 
directly to the bleeding vessels. The alum may be applied in a 
strong solution, or in powder on lint, and is one of the best; the 
perchloride of iron is now most used, and though rather irritating, is 
very useful. The persulphate of iron is also very powerful and use- 
ful. Tannin is less powerful than these mineral preparations, but 
often answers good purpose. 

Cold is also a useful means of arresting bleeding, in the form of 
cold air, douche, ice, etc. 

The actual cautery is peculiarly applicable to certain cases. 

Torsion, what and how used. 

Secondary hemorrhage is not necessarily preceded by primary 
hemorrhage, but may come on from a diseased or wounded part, 
where little or no hemorrhage had occurred before. The period of 
its occurrence is very variable — sometimes in a few hours, days, or 
even weeks. The bleeding often comes on without any assignable 
cause, suddenly and unexpectedly, and the loss of blood may be 
great before proper assistance is commanded. When it comes from 
a large vessel, death may be the consequence in a few minutes ; the 
scarlet hue of the blood denotes its arterial source. 

The principal causes which induce secondary hemorrhage are — 
1st. Faulty application of a ligature. 2d. Diseased state of the 
arteries. 3d. Improper traction on the ligature. 4th. Tight dress- 
ing or dependency of the part. 5th. A hemorrhagic diathesis. 6th. 
Spasm, or too much motion in a stump. Tth. Sloughing. 

Subcutaneous hemorrhage is where the blood comes from an 
artery wounded by a puncture, spicula of bone, or other cause ; pours 
the blood out beneath the skin, and it is extravasated through the 
cellular tissue and among the muscles, etc. It is sometimes poured 
out in very large quantity, distending greatly the parts, producing 
pain, numbness, oedema, and discoloration. 

There is more or less pulsation usually present, particularly in the 
early stage ; and on applying the ear near the wound, there is a pecu- 
liar thrilling or purring vibratory sound, such as is generally heard 
in aneurisms; and hence it has been denominated diffuse aneurism. 
The term, however, is not strictly proper, as^ there is no dilatation of 
the artery itself. The blood coagulates; pressure is produced on 
the surrounding tissues; inflammation, suppuration, and not unfre- 
quently sloughing follow ; and the patients may die from constitu- 
tional disturbance, or from bleeding. 



92 SYLLABUS. 

The treatment is the same as that for an open wound ; the artery 
must be tied at both ends, and the coagula cleared out. The opera- 
tion is often exceedingly difficult ; but this, or amputation in many 
cases, are the only resources. 

Collateral Circulation. — The manner in which the circulation is 
re-established in a limb, after the obliteration of the main artery. 

Hemorrhagic Diathesis. — By this term we mean a peculiar state 
of the system, in which, from a trifling wound, there is a strong 
tendency to the inordinate discharge of blood, and often difficulty in 
arresting and preventing its recurrence. The lives of persons are 
thus often put in danger from the most trivial causes. The hemor- 
rhage sometimes occurs from the rupture of small vessels in the mu- 
cous membrane of the nose, rectum, lungs, bladder and other parts ; 
even the extraction of a tooth may produce it in an alarming degree. 

In this variety of hemorrhage, the blood oozes out at every pore, 
and does not come in a stream as if from a vessel. This diathesis 
is sometimes seen in a whole family, or is hereditary. Of the causes 
we know nothing ; the prognosis is uncertain. 

The treatment is mainly such as is calculated to improve the con- 
dition of the blood, and give tone to the system generally. When a 
hemorrhage takes place, we should resort to astringents internally, 
such as the acetate of lead, tannin, etc. The condition of the sys- 
tem must be attended to, and indications met. If there is fever or 
derangement of the digestive organs, these should be removed, and 
then tonics, such as iron, quinine, vegetable bitters, etc., with fresh 
air and exercise, etc. 

Styptics, pressure, and caustics, must be resorted to for the imme- 
diate arrest of the bleeding, where they can be applied to the bleed- 
ing surface. 

DISEASES OF ARTERIES. 

Arteries, like other parts, are liable to inflammation, both acute 
and chronic, suppuration, softening, ulceration, and various trans- 
formations. 

Acute Arteritis. 

Acute arteritis is generally the result of a wound or the exten- 
sion of inflammation from a neighboring tissue; it may, however, 
come on as an idiopathic affection, particularly in gouty or rheumatic 
subjects. It is usually restricted to one artery, but occasionally be- 
comes wide-spread. 

Symptoms and progress of the traumatic and idiopathic forms. 



CHRONIC AFFECTIONS. 93 

Suppuration. — This sometimes occurs, but is much less frequent in 
arteries than veins. Gangrene is very rare. 

Softening of arteries is a common affection, especially in the smaller 
branches ; it is often an attendant on organic diseases, cancers, etc. 

Treatment. — This must be conducted on general antiphlogistic 
principles ; but the disease is difficult to control. 

Chronic Affections. 

The most usual of these are the fibrous, earthy, and atheromatous 
transformations ; they are of frequent occurrence, and particularly 
interesting from their connection with spontaneous aneurism. These 
transformations are almost peculiar to elderly subjects; they all ren- 
der the coats of the artery brittle, and generally occur together; 
they commence in the cellular tissue, between the coats of the ves- 
sels, which, however, are soon involved in the degeneration. 

"The fibrous transformation is characterized by the appearance 
of small, hard, firm patches beneath the serous coat of the arteries, 
usually isolated, but sometimes grouped together; of no definite 
shape, thin, and of a whitish, grayish, or pale yellowish aspect." 
When they are numerous, the artery is converted into a firm, inelastic 
tube. The deposit is originally fibrin. 

The earthy degeneration is most usual in old subjects after the 
sixtieth year, though sometimes seen earlier ; it is most common in 
the aorta and its primitive branches, though occasionally occurring 
in the smallest branches; much more common in males than females. 
I have seen every artery in the body that could be felt externally by 
the touch, in a female of twenty-three, transformed into hard, incom- 
pressible cylinders. The earthy matter deposited is phosphate and 
carbonate of lime, without the structure of bone, although it is some- 
times termed ossification ; it may be deposited in patches or rings. 
The effect is to render the artery brittle. 

The starting-point of this deposit is the subserous cellular tissue, 
whence it extends to the substance of the inner and middle tunics, 
both of which are sometimes completely transformed; the outer coat 
is rarely implicated. The cause is chronic inflammation. 

The atheromatous deposit, usually denominated fatty degenera- 
tion, is more frequent in Europe than this ^country ; and this seems 
to be the reason why aneurism is so much more common there, par- 
ticularly in Great Britain, than with us. 

This deposit, like the earthy, commences in the subserous cellular 
tissue, in minute, isolated points, not larger than the head of a pin; 



94 SYLLABUS. 

of a pale-yellowish, whitish, or brownish color, somewhat greasy to 
the touch, and of a semiconcrete, friable consistence. After a time 
these points coalesce and form irregular-shaped patches, which, push- 
ing the lining membrane before them, may involve the whole circum- 
ference, or extend several inches longitudinally. 

After a time the deposit softens, and is converted into a curdy, 
friable, or pap-like substance, resembling closely scrofulous pus. The 
lining membrane of the artery becomes elevated often into small pus- 
tules, or little abscesses, which, bursting, discharge their contents into 
the blood and leave little ulcers, whose base is formed by the middle coat. 

The fatty deposit is most frequent in the thoracic aorta and about 
the origin of the large vessels of the arch ; it is most common in 
the aged, the intemperate, and the gouty. Under the microscope 
the atheromatous matter consists of albuminous and earthy particles, 
of crystalline plates of cholesterine of an imperfect fibrous texture, 
and oil globules. The oily matter is often so great as to impart a 
greasy feeling to it. 

There is no treatment for these transformations. 

Ulceration, as a consequence of arteritis, is seldom seen; occa- 
sionally, however, it occurs, and may partially or entirely perforate 
the tunics; they vary from one to several lines in extent, and are 
usually caused by some of the transformations just described. 

Varicose Enlargement. 

The arteries may be dilated and nodulated, like veins, and are 
hence termed varicose. The affection has been described under the 
name of varicose aneurism and of aneurismal varix. The arteries 
become elongated, much dilated, and tortuous ; it is a very rare lesion, 
and is most frequent in superficial arteries, particularly in those of 
the head, forearm, leg, and foot, and seems to be the result of inflam- 
matory action. It may affect a small portion, or the entire artery; 
or it may affect one or many at the same time. When superficial, 
the diagnosis is easy ; when deep seated, it is impossible. 

Treatment. — It rarely requires any; if it gives inconvenience, it 
may be supported by bandage or other means. If it really gives 
serious inconvenience, the vessels should be ligated on the cardiac 
side of the enlargement. 

Aneurism. 

An aneurism is a pulsating tumor, occupied by blood and commu- 
nicating with an artery whose tunics are partially or entirely de- 



ANEURISM. 95 

stroyed. There is an occasional exception to this definition, where 
all the coats are entire, but such cases are extremely rare. The sub- 
ject has been much complicated by too much refinement in terms. 
There are, however, certain terms which are useful and should be 
retained; such are true and false aneurism; so with spontaneous 
and traumatic. The term varicose aneurism is also one not strictly 
correct, though it is in general use ; it is not an aneurism, but a 
dilated artery. Anastomotic aneurism is also another incorrect 
term, though generally adopted ; it is a hypertrophied state of the 
arterial and nervous capillaries of a part. It matters little whether 
these terms bear criticism or not, if we understand clearly what is 
meant by them. 

True Aneurism. — This term is applied to that variety in which 
one or more of the arterial tunics, without being necessarily perfect, 
form a part of the tumor. 

A False Aneurism is, on the contrary, one in which all the coats 
have given way, and the sac is composed of the surrounding cellular 
tissue in a condensed state. 

Each of these divisions comprises several varieties, founded prin- 
cipally upon the form and volume of the tumor : thus the sacculated, 
the cylindroid, etc. The terms circumscribed and diffused, refer 
merely to the dimensions of the aneurism. 

Any one or two of the coats may give way, and the sac be formed 
by the remaining one or two, in spontaneous aneurism. 

Locality. — Spontaneous aneurisms are more frequent in some parts 
than others. The aorta is the most common seat — at its origin, arch, 
or descending portion. Next come in frequency, the popliteal, the 
femoral, carotid, subclavian, innominate, axillary, and iliac. 

The causes for the appearance of aneurism in one artery in prefer- 
ence to another are obscure ; but there are, however, circumstances 
worthy of notice in this connection. 

Those arteries which are most prone to the degenerations, athero- 
matous, earthy, etc., of which we have spoken, are those most liable 
to aneurism. The degree of force with which the blood impinges on 
certain portions of a vessel may have much to do with their develop- 
ment. The degree of motion, too, to which an artery is subjected in 
sudden and violent efforts, as the aorta and popliteal, etc., is another 
cause. 






96 SYLLABUS. 

We have already alluded to the infrequency of aneurisms in the 
United States, compared to Europe. They seem to be more com- 
mon in New York than elsewhere, in our country. 

We have before said that true aneurism presents itself under 
the tubular and the sacciform varieties ; each may be composed of 
one or two tunics, and enlarge to an indefinite extent, and terminate 
in death. The sacciform is the most common, and is in the form of 
a pouch, sac, or bag, connected with the side of the affected artery. 
In the tubular variety, the entire circumference is involved. The 
sacciform variety presents many different forms : the most common 
is the globular or ovoidal; sometimes conical, elongated, or flat- 
tened. They also vary .much in dimensions. The attachment of 
the tumor to the artery is generally by a narrow footstalk ; at other 
times the base is broad. The size and shape of the opening varies 
greatly, as well as its position. 

The sac is usually composed simply of the external tunic, the inner 
and middle having given way ; and when this support is withdrawn, 
the dilatation commences, and continues until the pouch is formed. 
The sac would soon become greatly attenuated, and give way, did 
not inflammation in and around the sac take place, depositing lymph, 
by which its walls are thickened and glued to the surrounding tis- 
sues. It has already been stated that, in very rare cases, the sac 
may be formed of one or both of the internal coats. 

The sac varies in thickness, from a line to the fourth of an inch. 
It is sometimes very tough, consisting of several fibrous layers. The 
sac is rough on the outside, and smooth on the inside, but this also 
becomes rough after a time, from fibrinous deposits within. The 
dilatation goes on for months, often for years, till the sac finally 
becomes thinned, and gives way at some point, and death from inter- 
nal bleeding ensues. 

The sacciform aneurism always contains, even in the early period 
of its formation, fibrinous concretions, which seem to be designed to 
strengthen the walls of the tumor, and occasionally to bring about a 
spontaneous obliteration. These clots are concentric, like the layers 
of an onion. They differ much in color and consistence : the recent 
ones resembling coagula of blood, with the coloring matter more or 
less removed ; and those of long standing, of a pale, dense, fibrinous 
appearance. Their thickness varies from the thickness of one to that 
of several sheets of paper, and their number may extend to many 
hundred. They are organized, as is proven by their firm adhesion to 
each other and to the sac. There has been much discussion about 
the formation of these concretions. The fibrin of the blood seems 



ANEURISM. 9? 

to be deposited in successive layers, and to become organized — this 
is all we know about it. 

The Tubular Aneurism is extremely rare ; it is confined almost 
entirely to the aorta and its large branches, and consists in a uniform 
dilatation of the vessel, and is usually composed of all the tunics, 
more or less altered ; it is generally fusiform. It has also been de- 
nominated cylindroid. The coats become much and uniformly thick- 
ened, sustaining the pressure equally in every direction ; and it is a 
striking peculiarity of this form of aneurism, that it rarely gives way 
by rupture. It is also remarkable for the absence of fibrinous con- 
cretions. 

Symptoms of Aneurism. — Of these there will be found a want of 
correspondence in diiferent cases. 

In spontaneous aneurism, the first symptom is a sharp, sudden 
pain, marking the rupture of one or more of the tunics of the artery, 
and a pulsating tumor may be immediately discovered ; but this is 
very rare. In the great majority of cases the progress is slow, and 
the disease has made considerable advance before it attracts the 
patient's notice. In traumatic aneurism, on the contrary, the symp- 
toms are usually developed immediately after the receipt of the 
injury. The aneurismal tumor is at first small, not larger, perhaps, 
than a filbert, but may be gradually developed to the size of an adult 
head. It pulsates forcibly with the action of the heart to the touch, 
and the pulsation may, in well-developed cases, be seen across a 
room. It is soft, and in the early stages may be emptied by pres- 
sure. Upon applying the ear to the tumor a peculiar sound is 
heard : in general, it is a sawing, rasping, or bellows sound ; in other 
cases, it is a whizzing, whirring, or purring sound. It is much modi- 
fied by pressure on the artery above or below. It is very important 
to remark that, in large aneurisms, no pulsation or sound can be 
distinguished in many cases, in consequence of the thick fibrinous 
concretions within. 

There is more or less pain in aneurisms, depending mainly upon 
their seat, the parts pressed upon, and the degree of inflammation 
caused; there is also numbness from the pressure in the distal parts, 
and oedematous swelling, from pressure on the lymphatics and veins. 
From the obstruction to the circulation in the sac, the vessel beyond 
contracts and the collateral branches dilate.. 

Aneurism of the thoracic aorta, the innominate, and carotids, is 
nearly always attended with distressing dyspnoea, severe pain, and 
palpitation of the heart, which is itself often seriously implicated in 



98 SYLLABUS. 

the disease, being liable to suffer from hypertrophy, softening, and 
fatty degeneration, together with chronic endocarditis and disease of 
the valves. Death in these cases may be produced either by pres- 
sure, causing inflammation or asphyxia, or by the giving way of the 
sac, and hemorrhage. 

Diagnosis. — This is generally easy, but there are sources of error, 
and you cannot be too careful in making your decision. I have 
myself seen a distinguished surgeon plunge a bistoury into a popliteal 
aneurism, mistaking it for an abscess. 

The affections with which aneurism is most likely to be confounded 
are abscesses, glandular tumors, encephaloid growths, and empyema. 
The following are the best guides : — 

1. Aneurism is always, from the commencement, seated in the 
direction of one of the large arteries. It is soft and elastic; pul- 
sates more or less violently ; is free from pain ; and is unattended by 
discoloration of the skin. Abscess, on the contrary, begins as a hard 
swelling, and becomes soft only after the inflammation has passed 
through the earlier stages ; if chronic, matter will form very slowly, 
and although it may surround the artery, and thus receive its im- 
pulse, yet the peculiar fluctuation of the swelling, and the changes 
that may be induced in it by pressure and posture, will always suffice 
to prevent error. In acute abscess, there are all the symptoms of 
acute inflammation before fluctuation. 

Glandular lymphatic swellings are most common in the neck, axilla, 
and groin, and, when seated over an artery, may receive its impulse ; 
so with encephaloid growths ; but, if on your guard, they are easily 
distinguished. These tumors, when pressed upon, may seem to pul- 
sate, but if they are grasped laterally with the fingers and raised up 
from the artery, the pulsation ceases. 

2. Aneurism pulsates the moment it is developed — not so with 
abscesses. 

3. In aneurism, the tumor is firmly fixed, any attempt to grasp and 
raise it up proving abortive. 

4. The pulsation of aneurism is generally uniform, being perceived 
equally at every point of the circumference of the tumor, which rises 
and falls with the motions of the heart. This is not the case with 
tumors and abscesses. 

5. When an aneurism is firmly and steadily pressed upon, its bulk 
is diminished, from the expulsion of the blood from the sac. Tumors 
and abscesses are not diminished by pressure. 

6. In aneurism, the tumor is diminished by the artery above, and 
increased by compressing it below the tumor. 



ANEURISM. 99 

7. The sounds of aneurism are peculiar, but it should be remem- 
bered that a tumor, pressing on an artery and diminishing its caliber, 
may produce similar sounds. 

If doubt still exist, after all these points are considered, the explor- 
ing needle will probably settle the question. 

Effects and Termination. — The effects of aneurism are mechanical 
on neighboring parts ; and any organ or tissue, even bone, is destroyed 
by their constant pressure. Inflammation is often produced, and the 
function of any organ pressed upon may be destroyed. 

Spontaneous Cure. — This is of rare occurrence, but examples are 
occasionally seen. The following are the modes in which it may 
happen : — 

1. By the arrest of the circulation, through the aneurism, by fibrin- 
ous clots. 

2. Inflammation of the sac, producing coagulation of the blood. 

3. Gangrene of the sac. 

4. Compression by a tumor on the artery above, or by the sac itself 
turning over upon the trunk of the artery. 

5. By plugging of the artery below the sac by a small, detached 
clot. 

By whatever means the cure is effected, the result is the same : the 
absorbents set to work, the tumor and contents are gradually re- 
moved, and a little, hard nodule alone is left. This process may con- 
sume several weeks, or months, according to the size of the aneurism, 
the state of the part, and the system. 

There are three distinct modes by which aneurisms cause death: 
1st. By compression on organs. 2d. By rupture and hemorrhage. 
3d. By inflammation, suppuration, or mortification. 

Examples of each. 

Treatment. — Of internal aneurisms we have little to say under this 
head, as they belong more to the domain of medicine than surgery. 

Of the ancient modes, now abandoned, we need not speak. 

Deligation of the Artery at the Cardiac Side of the Tumor. — 

This discovery is due to John Hunter, of England, in the latter part 
of the last century. He reasoned well about the general principles 
of the operation, but performed it in a very faulty manner, having 
applied four ligatures loosely, instead of one small tight one. The 
patient, however, recovered, and the important principle was demon- 
strated, that aneurism could be cured by arresting the circulation 
through it on the cardiac side. 

The operation is now well established, and has been much simpli- 



100 SYLLABUS. 

fied since the time of Hunter. A healthy portion of the artery is 
selected; great care is taken in exposing the vessel, to disturb its 
sheath as little as possible, and only one ligature is employed, which 
is drawn sufficiently tight to divide the two internal coats ; the knot 
is tied firmly — one end of the ligature cut off near the artery, and the 
other brought out and retained at one corner of the wound. 

The pulsation usually ceases immediately, although sometimes it 
will continue, though much enfeebled, for several days. The obstruc- 
tion to the circulation in the latter case is sufficient to allow the 
blood to coagulate in the sac, and obliterate it eventually. The 
pulsation in these cases is kept up by the anastomosing branches. 
"When these branches are large or numerous, the circulation through 
the tumor may be sufficiently active to endanger the success of the 
operation. 

Generally speaking, after this operation, the temperature of the 
limb sinks below its normal standard ; and after a few days, when 
the vessels dilate, it may rise above this point. In other cases no 
change of temperature occurs. 

After-treatment. — This requires careful attention. The limb 
should be placed horizontally, and kept perfectly at rest. If the 
temperature is too low, it must be warmly covered, and, if need be, 
warm applications applied. Opiates may be given, if required, and 
indications must be met as presented. 

Causes of Failure. — The causes of failure after this operation are : 
violent inflammation followed by mortification ; death of the limb 
from deficiency of blood ; secondary hemorrhage from premature de- 
tachment of the ligature or rupture of the sac ; and lastly, continuance 
of the circulation through the sac by redundant anastomoses. The 
last accident is the one most likely to occur. 

The following statistics, showing the success of these operations, 
are quoted by Dr. Gross, from Inman, of Liverpool : — 

Names of artery. » Number of cases. Deaths. Proportion. 

Innominate artery 6 6 

Subclavian " 40 18 1 in 2 

Carotid " 40 11 1 in 4 

Abdominal aorta 3 3 

Common iliac 8 3 1 in 2| 

Internal " 4 2 1 in 2 

External " 21 9 1 in 3 

Femoral " 42 1 1 in 6 

110 59 1 in 3 



ANEURISM. 101 

Deligation of the Artery at the Distal Side of the Tumor. — It 

sometimes happens that the aneurism is so situated as to render it 
impossible to tie the vessel on the side of the heart, or it may be for- 
bidden by a diseased state of the artery itself. Bradsor, a French 
surgeon, supposing that the circulation would by this means be 
arrested in the sac, and the blood be allowed to coagulate, proposed 
to tie the vessel on the distal side. He did not live to make the 
experiment ; but it was successfully done by others, and particularly by 
Wardrop, who first succeeded and established its claims. He carried 
the principle a step further, by tying the subclavian to cure aneurism 
of the innominate artery, and succeeded in this experiment also. The 
latter operation, however, seems to be of little value, having failed in 
almost every case since. The operation of Bradsor, likewise, seems 
to have but little better success. 

Instrumental Compression. — The mode of treatment by compres- 
sion is very ancient, though not applied till recently in a scientific 
manner. The compression formerly was applied by various contriv- 
ances to the tumor itself, and particularly in traumatic aneurism ; the 
result usually was severe pain, inflammation, suppuration, gangrene, 
and death. 

It is needless to enumerate the many experiments which have been 
made by others, as it is due to Hutton and Billingham, of Dublin, 
to state that they first laid down proper principles for this mode of 
treatment, and put it in successful practice. 

Previous to the experiments of these gentlemen, it had been sup- 
posed necessary that the pressure should be so firm and constant as 
to inflame and obliterate the artery by adhesive inflammation ; but 
experience has taught that all this is unnecessary, and that the re- 
medy may be applied in a manner far more successful, and far less 
painful and dangerous. This mode of treatment is now superseding, 
to a considerable extent, the great discovery of Hunter; but still 
there will remain a certain proportion of cases which will be best 
treated by the ligature. 

Compression is more particularly applicable to popliteal aneurism, 
in which it has been very successful. It has also been successfully 
employed in aneurism of the lower part of the femoral artery, and in 
those of the brachial, especially at the bend of the arm. 

The compression is made at the point at which a ligature would be 
applied, viz., on the cardiac side of the vessel, at some short distance 
above the tumor, where the artery is most easily commanded. The 
compression is applied gently and intermittently, not firmly and 

8 



102 SYLLABUS. 

persistently, as in the old method ; just sufficiently to retard and 
weaken the circulation in the sac, not to arrest it, and so as to favor 
the gradual formation of clots, allowing time for the development of 
the collateral vessels. Occlusion of the artery at the point of com- 
pression is not desired ; on the contrary, it is better that the vessel 
should remain as nearly as possible in its normal condition, and per- 
vious. Stratum after stratum of coagula is deposited on the walls 
of the sac, which is filled by degrees, and with it the upper orifice of 
the artery. There are some exceptions, where a channel is still left 
and the blood continues to flow across the sac. 

For the purpose of making the compression, a variety of instru- 
ments have been contrived, which our limits will not permit us to 
describe. They may be found in detail in the works of Dr. Gross and 
others. 

In making the compression, it is always important, if possible, to 
make it opposite to a bone ; and during the treatment the limb 
should be kept well bandaged, from the distal extremity up, to sup- 
port the capillary circulation. The patient should be dieted, and 
kept perfectly at rest, and anodynes given when required. If swell- 
ing occur, the compression must be removed for a time. 

The time necessary for the cure varies much in different cases, from 
a few days to six or eight weeks, depending on the size of the tumor ? 
the tolerance of compression, and absence of complications. 

The statistics of Broca show 116 cures out of 127 cases, the num- 
ber of deaths not having exceeded half a dozen. If this treatment 
fail, the ligature, in proper cases, may still be resorted to. 

Digital Compression. — This mode of compression by the fingers 
has been successfully applied in a number of cases; its advantages 
are, that it is less painful, may be applied in some cases where other 
modes cannot be used, and the time required for the cure is much 
shorter, being from a few hours to a week. 

Galvano-puncture and injection are also means which have been 
used for the cure of aneurism, and although they have both been suc- 
cessful, the objection to them is that they may endanger life from in- 
flammation in the sac. 

Manipulation is another method recently introduced by Mr. Fer- 
gusson, of London, employed with remarkable success in several 
cases. It consists in forcibly squeezing the sac, breaking up the 
clots, and permitting them, by change of position, to embarrass the 
circulation in the sac and artery below. It is liable to the same ob- 



* 



ANEURISM. 103 

jection as the last modes of treatment alluded to, viz., inflammation 
and its consequences. 

Valsalva's treatment of internal aneurism consisted in bleeding, 
starving, absolute rest, etc.; in short, in reducing the circulation to the 
lowest possible point. It has occasionally succeeded, but very rarely. 

False Aneurism. 

False aneurism consists in a pulsating tiirnor filled with blood, and 
connected with an artery, the sac being formed by external tissues, 
and not by the tunics of the vessel. This term has been very loosely 
applied to various affections. It should be confined to two forms : 
one in which an artery alone is implicated, and the other in which an 
artery and vein are involved. We have already given reasons why 
the term diffuse aneurism should not be admitted. 

False aneurism is usually the result of a wound, stab, or puncture, 
and is more common at the bend of the arm, from the unskillful per- 
formance of the little operation of bleeding. The blood escapes 
from the wounded artery into the surrounding cellular tissue, which 
is soon condensed into a firm, pulsating cyst, which varies much in 
size. A spicula of bone, or other cause, may lead to the same result 
in this or other arteries. The cellular tissue is compressed, more or 
less inflammation ensues, fibrin is deposited, and a very firm cyst is 
often formed. 

The symptoms and progress of this form of aneurism are very like 
those of true aneurism. 

Treatment. — Compression may be tried, and is often successful. 
If this fail, an incision should be made over the sac, the artery ex- 
posed and tied above and below the tumor, as in the case of a wounded 
artery ; the tumor has then been dissected out by some, but it is best 
to leave it to the absorbents. It is necessary to apply a tourniquet 
previous to this operation. 

Yaricose Aneurism. 
The arterio-venous aneurism, generally called varicose aneurism, 
consists of a sac filled with blood,. lying between an artery and vein, 
and communicating with both. The most common site of this, like 
the last form of aneurism described, is the bend of the arm, and from 
the same cause, viz., venesection; the vein being completely trans- 
fixed, and the artery punctured by the lancet/ It may occur in other 
parts of the body, from wounds or ulceration. No matter how it is 
formed, the cyst is usually of small size, seldom equaling in bulk a 
pullet's egg ; it is composed of cellular tissue and plastic matter, and 



104 SYLLABUS. 

is often very thick and firm ; it does not cause much pain, but stiff- 
ness and numbness. The opening of communication between the 
two vessels is very small, and the blood rushes through with a pecul- 
iar whizzing or purring sound ; it is perceived both by touch and ear, 
and may be regarded as a satisfactory pathognomonic symptom. 
The sac rarely contains fibrinous clots, and on laying it open, is often 
found to be smooth and white like the interior of an artery. It sel- 
dom undergoes spontaneous cure, and may exist for years without 
increase or much inconvenience. 

Treatment. — When the tumor is small, and gives little inconveni- 
ence, it is best not to interfere. When it calls for relief, it must be 
cut down on, and the artery tied above and below the opening with- 
out interfering with the sac, which must be left to the action of the 
absorbents lest phlebitis should ensue. 

Aneurismal Yarix. 

Aneurismal varix consists in a direct communication between a 
contiguous vein and artery without the intervention of a sac ; in the 
last particular it differs essentially from the varicose aneurism. It has 
none of the characters of aneurisms, and should not have been classed 
with them, as is customary. It has the same cause as the last-named 
injury ; is most common at the bend of the arm, but may occur where- 
ever an artery and vein are contiguous. The opening between the 
vessels is very small, and the orifices of the two are glued firmly to- 
gether by adhesive inflammation ; the vessels are also firmly adherent 
for some distance beyond the point of communication. 

There is an incessant interchange and commingling of the two 
kinds of blood; the vessels undergo important changes, the vein 
assuming the characters of an artery, and the artery those of a vein. 
The vein becomes greatly distended for some distance above and be- 
low the point of communication, and its coats greatly thickened ; the 
artery, on the contrary, is diminished in caliber and the thickness of 
its coats ; owing to the blood passing from the artery into the vein, 
the latter pulsates like an artery, while the pulsation of the artery is 
enfeebled. At the seat of injury there is a purring sound like that 
described in varicose aneurism. 

Treatment. — This malady gives so little inconvenience that it rarely 
requires treatment; if any should be demanded, it is the same as for 
varicose aneurism. 

Aneurism of Particular Arteries. 

Aneurism of the Innominate Artery. — It may exist alone, or be 
associated with aneurism of the arch of the aorta, the carotid, or sub- 



ANEURISM. 105 

clavian ; it may be very small, or enormously large and tubular, fusi- 
form, or sacculated. Sometimes it is limited to the middle of the 
vessel ; at others it involves one or both extremities. 

Symptoms. — Aneurism of the innominate usually begins as a small 
tumor at the right sterno-clavicular articulation, between the trachea 
and inner margin of the mastoid muscle, immediately above the inner 
third of the clavicle. The tumor is at first very small, circumscribed, 
and movable on pressing the finger down into the hollow at the top 
of the sternum. 

The growth is usually rapid, extending upon the neck and to either 
side, particularly to the right, where there is least resistance. As it 
advances it pushes forward the muscle, and even the bony articulation, 
forming a large prominence, pulsating violently beneath the skin. 
Now and then it escapes from the chest, and advances a considerable 
distance up the neck, presenting an hour-glass shape. 

The effects upon neighboring structures are striking, and give rise 
to great distress. The pressure upon the subclavian weakens the 
force of the circulation at the wrist, and sometimes arrests it entirely. 
The circulation is occasionally irregular and intermitting in this arm. 
The. circulation of the right carotid may be affected in like manner. 
Compression of the tumor on the veins often produces oedema of 
head, face, and arm. 

The trachea becomes pressed upon and displaced, and the difficulty 
of breathing becomes so distressing that the patient is unable to lie 
down. Dyspnoea, however, is less frequent from aneurism of the in- 
nominate artery than that of the arch of the aorta, which is explained 
by their anatomical relations. The oesophagus is also sometimes 
pressed upon, and deglutition interfered with. When the aneurism 
occupies the inferior part of the artery, its pressure is downward on 
the heart, arch of the aorta, and vena cava, compressing them, and 
interfering with their functions. 

Pressure of the tumor on the nerves of the neck and chest induces 
not only pain and cough, but dyspnoea and dysphagia ; the two latter 
symptoms not being necessarily dependent on compression of the 
trachea and oesophagus. Compression of the pneumogastric, phrenic, 
laryngeal, and sympathetic will readily account for the symptoms 
alluded to. 

Effect of pressure on bones. 

Diagnosis. — This is sometimes extremely^ difficult, as aneurism of 
the innominate may be confounded with those of the arch of the aorta, 
carotid, or subclavian. Fatty, fibrous, and encysted tumors, situated 
about the root of the neck and behind the sterno-clavicular articula- 



106 SYLLABUS. 

tion, receiving the impulse from the innominate or aorta, may simu- 
late this aneurism. A doubt may arise even in the case of anaemia, 
where the pulsation of the innominate and aorta are inordinate, 
though there is no dilatation. The difficulty in such cases is much 
increased in fat subjects. By strict attention, however, to the symp- 
toms before laid down, a satisfactory diagnosis may usually be made. 

The prognosis is very unfavorable ; death ensuing from bursting 
externally or internally, or from pressure on the trachea and sur- 
• rounding parts. 

Treatment. — The only chance of success is from tying either the 
carotid, subclavian, or both. The success of any one of these oper- 
ations is unsatisfactory, but the ligature of the carotid gives best 
promise, two out of eleven having recovered. 

Aneurism of the Common Carotid. — Tt may occur at any point of 

its course, but is most frequent about the middle portion. Like 
other aneurisms, it commences in a very small, pulsating tumor of 
rounded shape, and usually without any known cause. The surgeon 
rarely sees it until it has acquired the size of a pullet's egg, the pa- 
tient having most probably taken it for swelling of a gland. . Its 
pulsation, thrill, and bellows sound, however, reveal its true nature. • 
Pressure on the cardiac side of the aneurism, by stopping its circula- 
tion, arrests these symptoms, and causes a diminution in the size and 
consistence of the tumor, while pressure upon the distal side produces 
an opposite result. When small it is easily moved about, but as it 
increases it becomes more firmly fixed. 

The tumor, as it enlarges, produces more and more inconvenience 
by pressing on the trachea, the nerves, and soft parts around, and by 
obstructing the return of blood from the brain by pressure on the 
veins. 

Carotid aneurism may be confounded with diseased lymphatic 
glands, abscesses, encysted tumors, goitre, dilatation of the internal 
jugular vein, and aneurism of the innominate and aorta. The diag- 
nosis often requires much caution. 

Treatment. — The treatment of this aneurism is usually conducted 
on the Hunterian principle, by tying the artery on the cardiac side, 
when there is sufficient space for the operation. If the tumor is low 
down we resort to the operation of Bradsor, by tying the artery on 
the distal side of the tumor. Treatment by compression is here in- 
applicable on account of the arrest of the return of the venous blood 
from the brain. These operations have been performed with gratify- 
ing results, a very large proportion having been successful. 



ANEURISM. 



107 



Aneurism of the Subclavian. — This is almost as common as that 
of the carotid. It may affect any part of the artery, but is most 
common beyond the scaleni muscles, just before it becomes the axil- 
lary. The form of this aneurism is much influenced by the compres- 
sion of the surrounding muscles and other tissues. 

As the tumor enlarges, it encroaches upon and compresses the 
surrounding parts, causing pain, oedema, elevation of clavicle, dysp- 
noea, dilatation of the veins of the neck, chest, and upper extremity, 
and numbness, or even paralysis. At first movable, it after a 
time becomes firmly fixed. To the hand and ear the peculiar thrill 
and sound of aneurism are revealed. This aneurism has been con- 
founded with those of the innominate and aorta, and with various 
tumors and abscesses. The vessel has actually been ligated by mis- 
take for aneurism when none existed. 

The history of the tumor, and its situation at the side of the neck, 
just above the clavicle, with the symptoms peculiar to aneurism, will 
generally enable us to avoid such blunders. When the tumor is 
within the scaleni muscles, it is situated behind the mastoid muscle, 
and extends toward the middle line of the neck. When it com- 
mences on the outside of the scaleni, the situation of the tumor will 
be behind the mastoid muscle. If the position and symptoms of 
aneurism of the innominate artery be remembered, we may usually, 
in the early stage, make a clear diagnosis between them. Like other 
aneurisms, its effects depend much upon the parts compressed in its 
course. 

Treatment. — If not arrested by art it is almost necessarily fatal, 
nature being rarely equal to a cure, and our art is not more potent 
than nature. Ligation of the innominate has been tried without suc- 
cess. There is rarely any space left of the subclavian itself for a 
ligature, and if there is, the artery is almost certain to be too much 
diseased to bear it. 



sr't ] 

■ t 

ft 



Axillary Aneurism. — Less frequent than the subclavian. Size of 
the tumor may reach the size of a foetal head. 

Symptoms. — These are mostly well marked. It presents all the 
ordinary symptoms of aneurism, and there being no other large 
vessel near, the diagnosis is easy. 

Treatment. — The only remedy is ligation of the subclavian artery, 
and the sooner the better. 



108 SYLLABUS. 



Aneurism of the Brachial Artery and its Branches. — Spon- 
taneous aneurism of these arteries is extremely rare, for the reason 
that they are little liable to those degenerations so common to the 
large arteries. They are, however, all subject to traumatic aneu- 
rism, particularly from venesection, as before stated. The treatment 
of them, as well as wounds of these arteries, have already been 
spoken of. 

" Wounds of the arteries of the hand, especially of the palmar 
arch, are best managed by free incision, and the application of two 
ligatures." The compression, direct or indirect, is a useless loss of 
time. The bleeding returns when the support is removed, more 
blood is lost, the parts become inflamed and swollen, and the appli- 
cation of ligatures much more difficult of application. The ligation 
even of both the radial and ulnar arteries in the forearm is often not 
sufficient to arrest the hemorrhage, the interosseous and other anasto- 
mosing branches still keeping up the supply of blood to the wounded 
artery. The brachial artery has been often tied to arrest hemorrhage 
from the palmar arch, but rarely with success, as the anatomist might 
expect. 

Aneurism of the Common Iliac. — This affection is fortunately ex- 
tremely rare, as we have no remedy for it. The aorta has been tied 
five times with the hope of relief, but all the subjects died. 

Aneurism of the Internal Iliac. — Also rare, and, like the last, dif- 
ficult of diagnosis. 

Aneurism of the External Iliac. — Yery rare. May be seated at 
any part of the artery, but generally is low down, and has a tendency 
to pass beneath Poupart's ligament, into the upper part of the thigh. 
It presents all the ordinary symptoms of aneurism, attains very great 
size, and displaces the parts around. In thin subjects, by compress- 
ing the abdominal aorta with the hand, the size of the tumor is di- 
minished, and the pulsation arrested. The diagnosis, however, is 
not always easy, and the common iliac has been ligatured for tumors 
over the artery, instead of aneurism. There is numbness and swell- 
ing of the limb, with much discomfort. 

Treatment. — Deligation of the common iliac, or of the upper part 
of the external iliac, where space permits, is the only remedy. Com- 
pression with the fingers, of the iliac where it passes over the brim 
of the pelvis, has been recommended, and, I believe, practiced in one 



Mi 






f 



ANEURISM. 109 

case, that of Dr. Nichols, with success. The ligature has met with 
sufficient success to justify the operation in proper cases. 

Aneurism of the Femoral Artery. — This is more common than 
those of the iliacs, though not so frequent as the popliteal. The 
superior third suffers more than other parts of the artery. Sailors 
are said to be more subject to this form of disease than others, from 
the mechanical injury they are exposed to. 

Diagnosis. — This is generally, though not always, easy. Abscesses, 
and various morbid growths — solid, semisolid or fluid, and malignant 
and non-malignant — are the affections with which it is most liable to 
be confounded. The best diagnostic, where space permits, is com- 
pression above the tumor. If the tumor is aneurismal, the compression 
will arrest the pulsation, thrill, and sound, and permit the tumor to 
be diminished by compression. Where doubt still exists, a very fine 
exploring needle may be used. 

The femoral artery, at its upper part, may be pushed forward by a 
synovial bursa, situated behind the psoas muscle, just below Pou- 
part's ligament, which may receive an impulse from the artery. If 
the thigh be flexed upon the pelvis, the tension is taken off from the 
muscle, and the pulsation arrested. There are a great many lym- 
phatic glands on the upper part of the thigh, over the artery, and, 
when enlarged, these have been mistaken for aneurism. 

Psoas abscess has also been mistaken for aneurism, but the history 
of the case and symptoms are very distinct ; if a patient with this 
abscess be laid down, and the pelvis elevated, the tumor can easily be 
made to disappear by a little pressure. 

Treatment. — This aneurism may be cured generally by properly- 
managed compression, either with the fingers or mechanical appara- 
tus. Where this fails, the artery should be ligated, and the operation 
is one easily performed. 

Popliteal Aneurism. — After the thoracic aorta, this is the most 
usual point of aneurism, and is spoken of by writers as of frequent 
occurrence. It is, however, very rare in our part of the world, as I 
have seen or heard of but one case in Alabama, during twenty-five 
years I have been practicing surgery in Mobile. It almost invariably 
occurs in males, and beyond the middle age of life, and is most gen- 
eral among the laboring classes. In its early stage, being small and 
deep seated, the diagnosis may be difficult; but when it has reached a 
certain magnitude, it is rarely to be mistaken. I have, however, seen 
a no less distinguished surgeon than Dr. Stone, of New Orleans, 






110 SYLLABUS. 

plunge a bistoury unexpectedly into a popliteal aneurism, and be 
compelled at once to apply a ligature to the femoral above. In this 
case the doctor diagnosed an abscess, in which he was correct, but 
not discovering the aneurism, and the abscess being superficial, the 
bistoury passed through the abscess and into the aneurismal sac, from 
which the blood spouted forth. The tumor is seated at the bend of 
the joint, behind the knee, and in the hollow between the outer and 
inner ham-string muscles, and presents all the symptoms of aneurism 
already described. The leg is bent, and there is numbness, pain, and 
swelling of the limb below. It has been confounded with abscess, 
tumors, bursse, etc. The progress of the disease is like that of other 
aneurisms. The Hunterian operation, till recently, has been the only 
reliable remedy, but is now being superseded by compression, which 
has been remarkably successful in these cases. 

Aneurism of the Arteries op the Leg and Foot. 

These are exceedingly rare, particularly in the spontaneous form. 
The traumatic form occasionally occurs, and when affecting the pos- 
terior tibial, is extremely difficult to get at, from the great depth of 
the vessel. 

Injuries of the arteries of the foot, followed by troublesome hem- 
orrhage, are often exceedingly embarrassing to the surgeon, and re- 
quire all his self-possession and anatomical knowledge. The anas- 
tomoses of the arteries, like those of the palm of the hand, are so 
free that the surgeon's work must be thoroughly done to put an end 
to the trouble. Experience has proved that compression cannot be 
relied on but in exceptional cases. The rule is, that the plantar 
arteries, when divided, will bleed till ligatured, and they should there- 
fore be commanded by this remedy at once. An ugly wound is 
required, and the operation is often troublesome, but the necessity 
still exists ; it is absolutely necessary, too, that both ends of the artery 
should be tied. 

It has been recommended to cut down upon the large arteries of 
the leg, or even the femoral, in such cases, but such a procedure can- 
not be too strongly condemned. The experiment of tying both tibial 
arteries has been tried again and again, and almost always without 
success. 

Sometimes we may resort to the expedient of compressing the 
anterior and posterior tibial arteries by means of two pieces of cork 
placed directly over the vessels, opposite the malleoli, and bound 
down firmly by a bandage. 



OPERATIONS ON ARTERIES. Ill 



OPERATIONS ON ARTERIES. 

Ligation of the Innominate or Brachiocephalic. — I think it 
needless, in a course like this, to waste time on an operation which 
has always failed, and promises no success for the future. 

Ligation of Common Carotid. — There are two points in its course 
at which a ligature may be applied, at its upper or lower part. As 
the artery proceeds upward, it is overlapped by the sterno-mastoid, 
sterno-hyoid, and sterno-thyroid muscles, and crossed by the omo- 
hyoid toward its superior extremity. Running down in front of its 
sheath is the descendens noni nerve, a little thread-like filament, 
easily recognized by its whitish appearance, while within the sheath 
are, on the external side of the artery, the internal jugular vein, and 
behind and between them the pneumogastric nerve; the sympathetic 
and recurrent nerves being posterior to the sheath. All these parts 
are in close proximity, and require great caution in separating them 
before the ligature is applied. The difficulty of the operation is 
sometimes much increased by overlapping and distention of the vein, 
thus concealing the artery. This is best remedied by requesting an 
assistant to compress the vein at its upper and lower parts, having 
first stripped out the blood. 

It sometimes happens that the common carotid is wanting, two 
branches coming off and running parallel, thus forming the external 
and internal carotids; or the common carotid may bifurcate lower 
down than usual : but these and other irregularities must be met as 
they present themselves, which is not often. 

In ligating the artery, the patient should lie on his back, with the 
head inclined to the opposite side, and well supported by pillows; 
the shoulders should be elevated and the neck well exposed. 

The artery is easily exposed in the lower part of the neck, by 
making an incision, from two and half to three inches in length, along 
the inner border of the sterno-cleido-mastoid muscle, commencing 
far above the clavicle. The skin and platysma myoides being 
divided, a portion of the cervical fascia is pinched up with the 
forceps, and opened transversely sufficiently to admit a grooved direc- 
tor, upon which it is then slit up to the extent of the outer incision. 
Two retractors are then inserted to draw the parts asunder. The 
sheath of the artery being thus exposed, a small portion is raised 
with the forceps, and divided horizontally, when the director being 



' 



I 



f 



,o, 



112 SYLLABUS. 

introduced, it is slit open so as to denude the artery to a small ex- 
tent and enable the operator to isolate it from the jugular vein and 
pneumogastric nerve, the ligature being passed from without inward. 
Any superficial vein lying in the way must be pushed aside. 

The artery being of more easy access in the upper than lower part 
of the neck, this should if possible be selected for ligation. To ex- 
pose the vessel in this situation, an incision should be made along 
the inner margin of the mastoid muscle, commencing a little below 
the cricoid cartilage and extending nearly to the angle of the jaw 
above. The same layers are cut through as in the last operation, for 
the exposure of the artery, and the ligature is passed in the same 
way around the artery, from without inward. The omo-hyoid mus- 
cle crosses the sheath of the vessels at this point, serves as an im- 
portant guide, and must be held aside. The common carotid has 
been tied for various other reasons than the cure of aneurism, viz., 
for arresting hemorrhage from wounds ; as a preparatory step in the 
extirpation of tumors ; to prevent hemorrhage ; for the cure of epi- 
lepsy ; for the cure of erectile tumors, etc.; and the details of these 
operations present many points of interest and instruction. 

Ligation of the External Carotid and its Branches. — -The ex- 
ternal carotid is situated in the triangular space formed by the omo- 
hyoid muscle below, the digastric above, and the sterno-mastoid 
externally and immediately below the platysma myoides; it extends 
from the upper border of the thyroid cartilage to the neck of the 
lower jaw; as it passes up, it sinks deeper, and dips beneath the 
stylo-hyoid and digastric muscles, and is finally buried in the sub- 
stance of the parotid gland. It is accompanied by two veins, and is 
crossed near its commencement by the hypoglossal nerve, and in 
various parts of its course by branches of the external jugular and 
other veins. The glossopharyngeal nerve passes between this artery 
and the internal carotid, while the superior laryngeal nerve lies under- 
neath. 

This artery rarely requires a ligature for anything else than wounds 
or vascular growths about the head and face. A ligature is easily 
placed around it, in the first part of its course, by making an incision 
along the inner edge of the sterno-mastoid muscle, commencing oppo- 
site the middle of the thyroid cartilage, and extending it two inches 
up to the angle of the jaw. The trunk of the common carotid will 
serve to direct the finger to the point of bifurcation ; where it lies 
beneath the digastric and stylo-hyoid muscles, the artery is exposed 
with more difficulty, and requires cautious dissection. 



OPERATIONS ON ARTERIES. 



113 



The branches of the external carotid likely to require ligation are 
the superior thyroid, lingual, facial, occipital, and temporal ; and if 
you make yourself well acquainted with their anatomical relations, 
little difficulty will oppose you. 

Ligation of the Subclavian Artery. — Although one of the most 
important operations in surgery, it is by no means the most difficult 
to one who understands well the anatomy of the parts. The point 
which is usually selected for the operation is just external to the 
scaleni muscles, where it lies upon the first rib. For the operation 
the patient should be placed in a recumbent position, with the 
shoulders and head elevated, and the latter turned to the opposite 
side. An assistant takes hold of the hand of the affected side, holds 
it close to the side, and draws the shoulder down in order to press 
the clavicle as much as possible downward, which has the effect of 
making the artery more superficial. 

The surgeon then, standing beside the patient, places his left hand 
upon the chest below the clavicle, draws the integuments downward, 
holds them firmly, while he makes an incision, about two inches and a 
half long, directly along the middle line of the clavicle, commencing 
at the clavicular origin of the mastoid muscle, and terminating near 
the anterior margin of the trapezius; in this manner the skin, pla- 
tysma myoides, and superficial fascia are divided. Letting go the 
parts, the skin will resume its natural position, and the incision be 
found along the upper margin of the clavicle. The next step is to 
work your way gently with the handle of the knife through the deep- 
seated fascia and cellular tissue. The external jugular vein will be 
found close to the external border of the mastoid muscle, and must 
be pushed aside. The supra-scapular artery will usually be found 
along the inner border of the clavicle, and must be carefully guarded ; 
if divided, it should be immediately tied. 

The finger is then introduced into the wound, the anterior scalenus 
muscle felt for, which is easily found ; the finger is next placed on the 
outer edge, and glided along down to the first rib, where the tubercle 
is felt, and the artery pulsating immediately behind, where it may be 
easily tied by passing a ligature beneath, and from before backward. 
Before tightening the ligature, you should be sure that it controls 
the circulation which feeds the aneurism, and that you have not in- 
cluded a branch of the axillary plexus of nerves. If the mastoid 
muscle is very broad, it may be necessary to clivide some of the fibres 
of the clavicular portion. Where the aneurism is very large, the 
operation is sometimes rendered more difficult, by the elevation of 



I 



114 SYLLABUS. 

the clavicle. The clavicle is naturally more elevated in some sub- 
jects than others, and the operation is also much more- difficult in fat 
subjects, and those with short necks. 

The operation is sometimes embarrassed or rendered useless by a 
diseased state of the artery at the point of ligation. In this case it 
may be necessary to divide the anterior scalenus and tie the artery 
higher up. The operation is usually more or less interfered with by 
interposing blood-vessels. The external jugular vein and supra- 
scapular artery, in their normal position, stand directly in our way. 

It occasionally happens that the subclavian vein is so distended 
as to interfere greatly. This vessel is situated lower down usually 
than the subclavian artery, and in front of the scalenus, while the 
artery is behind. 

This operation is one which requires to be studied out in detail, 
for while the artery is easily reached in the normal state of the parts, 
there are many circumstances that embarrass the operation. 

Ligation of the Axillary. — This is required principally for pene- 
trating wounds or rupture of the artery. It may be secured just 
below the clavicle, or in the axilla. These are both rare operations. 
The operation above the clavicle is easier to perform than the one 
below, and I should take the operation just described, almost univer- 
sally, in preference to the one below the clavicle. The operation in 
the axilla may, in rare instances, be called for, and the artery is got 
at by abducting the arm, making an incision along the center of the 
hollow of the axilla, near the latissimus dorsi muscle. The median 
nerve and axillary vein first come into view, the two roots of the 
former embracing the artery on each side, and the latter running 
along its anterior surface. These must be cautiously pressed aside 
and the artery brought into view. 

Ligation of the Brachial. — This artery has to be ligated more 
frequently than any other, and fortunately is one of the easiest to 
get at. To secure it high up, an incision, two inches and a half in 
length, should be made along the inner margin of the coraco-brach- 
ialis, the arm being extended and supinated. The artery is accom- 
panied by two veins, and here lies between the median and ulnar 
nerves, the former being on the outer, and the latter on the inner side. 
In the middle of the arm the artery is easily reached by an incision 
along the inner border of the biceps ; the median nerve here usually 
lies on the inside and in front of the vessel. At the bend of the arm 
the artery is readily exposed, by making an incision through the skin 
and aponeurosis at the inner edge of the biceps tendon. 



DISEASES OF THE VEINS. 115 

It would be a useless consumption of time to go over in detail the 
application of ligatures to all the arteries. These operations may 
be turned to in any of your surgical books, and will be shown you in 
the course of our lectures. 



INJURIES AND DISEASES OF VEINS. 

Wounds of veins are rarely accompanied by danger, and require 
much skill in treatment. The color of the blood, and the manner in 
which it flows, usually declare the kind of vessel that pours it forth. 
Where the veins are large and beyond the reach of ligature or com- 
pression, the hemorrhage is often fatal ; in the smaller veins, whether 
the vein be wholly or partially divided, nature generally arrests the 
hemorrhage, though sometimes after too much blood is lost. There 
is not only danger from loss of blood, but from inflammation of the 
vein, as occasionally happens from a foul lancet or other cause. 

Treatment. — In wounds of veins, a compress and bandage is ordi- 
narily all that is required, together with rest and position. A vein 
should never be tied if the operation can be avoided, as these vessels 
are much more liable to serious inflammation than arteries. This, 
however, often becomes necessary. 

DISEASES OF THE YEINS. 

Phlebitis, or inflammation of the veins, is sometimes an idiopathic 
affection, but generally is the result of injury. It frequently follows 
surgical operations and other wounds, in which case it is apt to 
cause pyemia, or multiple abscess, a fatal form of disease. Phlebitis 
is not only more common than arteritis, but is more apt to terminate 
in suppuration; another peculiarity of phlebitis, is its tendency to 
extend along the vessel toward the heart ; this affection may be con- 
fined to one vein, but usually affects several. It may be also acute 
or chronic. 

Acute Phlebitis. — The symptoms of this affection are not always 
well marked. When the affected .vessel is superficial, its course is 
indicated by a corresponding red line, which, on applying the finger, 
feels like a hard cord; exquisitely sensitive to the touch, and reach- 
ing as'high as it can be traced. The color is more or less red, and 
soon becomes diffused over the surrounding parts, presenting all the 
characters of erysipelas; swelling and pitting accompany it. The 
pain is severe. 



> a 



* 



116 SYLLABUS. 

The constitution always deeply sympathizes, even in the cases 
where the disease is limited in extent. The disease is ushered in by 
rigors, flushes of heat; the pulse is frequent, quick, and irritable; 
skin hot and dry; nausea; constipation, and scanty urine. Ady- 
namic symptoms soon set in ; excessive prostration, delirium, jaun- 
dice, great restlessness, are usual attendants. 

Anatomical characters. 

Treatment. — Where it involves only the superficial veins, it often 
yields to the antiphlogistic treatment, together with local application 
of blisters, iodine, etc. 

Chronic Affections. — Chronic inflammation of veins differs greatly 
from the acute form. The coats become so much thickened as to re- 
semble those of an artery. The surface of the vein does not present 
the vivid redness and other marks of acute inflammation. The sur- 
face is rough and shriveled ; the inflammation sometimes passes on 
to ulceration, but this is more rare than in the arteries ; sometimes 
the coats are eaten through, and fatal hemorrhage ensues. These 
ulcers may be solitary or numerous. 

Chronic phlebitis is most common in the lower extremities, in the 
veins of the spermatic cord, and those of the rectum. The symptoms 
are those of inflammation in the chronic form. 

The treatment is antiphlogistic, and it is important to remove the 
cause. 

Obliteration of veins is not an unfrequent result of inflammation, 
compression of tumors, etc. 

Loose concretions, phlebolites, or vein stones, as they are termed, 
varying in size from a currant to a pea, are occasionally found in the 
veins; commonly of a yellowish, brownish or bluish color, they are 
of a hard and brittle consistence, and oblong, oval or spherical form, 
with a smooth and even surface. When divided, they are found to 
consist of concentric lamellae, around a nucleus, frequently consisting 
of fibrin. There are sometimes as many as twenty or thirty of them ; 
they are generally found in the smaller veins ; they are more often 
seen in varicose veins, and consist of carbonate and phosphate of 
lime, with animal matter. 

Varix. — A varicose or enlarged state of the veins in the lower ex- 
tremities is very common, particularly among the laboring class and 
those who are much in the erect posture. The veins of the spermatic 
cord, vulva, scrotum, and rectum are the usual seats of this affec- 



DISEASES OF THE VEINS. 



117 



tion, which is rarely seen in the upper extremities. In the spermatic 
veins it is most common in young subjects, while the hemorrhoidal 
veins and those of the leg are most often affected in the middle and 
later years of life. The veins, in this affection, are preternaturally 
large, tortuous, knotty, and convoluted, or as if they were folded on 
themselves, being increased both in diameter and length, and pursue 
a singularly serpentine course. Their coats are much thickened and 
condensed, elastic, and rolling under the finger like cords. In some 
points they are thin and dilated into pouches, and often give way, 
pouring out large quantities of blood. 

On being opened, the surface is found rough and sacculated irregu- 
larly, strong bands being sometimes stretched across their interior, 
which divide the tube into small cells, occupied by coagulated blood, 
phlebolites, or fibrinous concretions, in a state of organization. The 
valves are often broken down, or thickened, indurated, and displaced; 
occasionally a vein is obliterated, and all the above changes are results 
of inflammation. 

Causes. — Obstruction of the veins, however produced, is a common 
cause ; pregnancy, from the pressure of the gravid uterus on the large 
veins of the pelvis ; tight garters, drawers, or stockings, or even the 
erect posture habitually maintained, may produce it. Yarix of the 
rectum is generally the result of constipation and straining at stool. 
The cause of varicocele is not well understood. 

The effects of varicose veins vary much, according to situation. 
In the legs, from the length of the veins and gravitation of the 
column of blood, it is productive of a good deal of pain and discom- 
fort, of tumefaction of the skin and cellular tissue, and more or less 
tenderness along the track of the vessel. In the aggravated forms, 
ulceration often occurs in the skin, commencing at a small spot and 
extending to considerable size, and is called varicose ulcer ; it is dif- 
ficult to heal, and the ulceration sometimes extends into the veins, 
causing hemorrhage. 

In the spermatic veins, the disease may give rise to atrophy of the 
testicle and distressing neuralgic pains. In the hemorrhoidal veins, 
it gives rise to piles and other disagreeable symptoms. 

The progress of varix is generally, though not always, slow. In 
pregnant females, during the last months, this varicose condition 
often comes on rapidly, and to great extent. The disease is also 
occasionally developed rapidly in the spermatic and hemorrhoidal 
veins. 

In the lower extremity it may remain stationary for years, and in 

9 



m 



** /V 



118 SYLLABUS. 

some cases spontaneous cures take place by adhesive inflammation. 
On the other hand, this affection leads sometimes to ulceration, 
abscess, violent erysipelas, etc. Yaricocele and varix of the hemor- 
rhoidal veins never prove fatal, but give rise to much discomfort and 
suffering. 

Treatment is either palliative or radical. The cause must be re- 
moved. Onanism is one of the causes of varicocele ; and constipation, 
of varix of the hemorrhoidal veins. In varix of the lower extremity 
all impediments to the circulation must be removed, and artificial 
support given by suspensory bandages, laced stockings, etc. An 
active purge occasionally is beneficial, in unloading the portal circu- 
lation. In plethoric persons, the lancet sometimes gives much relief. 

For the radical cure of this disease many operations have been 
devised, most of which are not worth alluding to. The ligature and 
caustic seem now to be most relied on for cure. As veins inflame 
more easily than arteries, the patient should always be carefully pre- 
pared for it, by rest, diet, position, local remedies to remove irrita- 
tion, purging, etc. 

"The operation with the ligature is either direct, as in piles, or 
subcutaneous, as in varicocele, and in either case it is safe and 
effectual." (Gross.) 

The ligature requires to be drawn tightly, in order to obliterate 
the vessel. Of hemorrhoids we shall speak elsewhere. In varico- 
cele, a stout spear-pointed needle is used ; the veins are drawn aside 
from the spermatic duct, and the needle passed through the integu- 
ments behind them, and brought out at the opposite point of the 
integuments ; the needle is then passed in at the opening from which 
its exit was made, carried in front of the veins, and then brought out 
at its point of entrance ; the two ends are then tied firmly, embracing 
and strangulating the isolated veins of the cord. 

In operating on the lower extremities, Dr. Gross gives a decided 
preference to the issue prepared with equal parts of caustic potash 
and quick lime, carefully incorporated and converted into a thick 
paste with alcohol. Of this, a portion of the size of a three-cent 
piece, and a line or two in thickness, is placed directly over the en- 
larged and tortuous vessel, at intervals of three, four, or five inches, 
and allowed to remain fifteen minutes, by which time a deep eschar is 
formed. The paste is now removed, and the parts washed with vin- 
egar, to neutralize the alkalies, and a poultice applied. The cure is 
sometimes tedious, from the difficulty of curing an issue of this kind, 
but the remedy "is entirely free from danger, and is always perfectly 
successful." (Gross.) 



AFFECTIONS OF THE CAPILLARIES. 119 

The other mode of treating varicose veins of the lower extremities 
is by pins passed beneath the vein, and then winding a thread firmly 
around the pin, so as to constrict the vein. 

Authors differ greatly as to their estimate of these two operations, 
and the encomiums passed on the caustic by Dr. Gross are much 
higher than the opinion of the profession generally would justify. 
The obliteration of veins, by any operation, (though it may be free 
from danger,) is unsatisfactory, as the disease is almost certain to 
return in the lower extremities, — the cause, whatever it may be, not 
being reached by the operation. - 

Introduction of air into veins is a serious accident, which some- 
times occurs in operations, particularly those about the neck. An 
opening being made into one of the jugulars or subclavians, the air, 
during inspiration, rushes into the circulation, and death has been 
the consequence within half an hour. 

The symptoms are very like those of cerebral apoplexy, and the 
patient dies in coma. 

Treatment. — There is nothing satisfactory under this head. The 
important point is to prevent the ingress of air. 

Affections of the Capillaries. 

These vessels are liable to enlargement or hypertrophy, which may 
be confined to the arterial capillaries, the venous, or may involve 
both. This affection is usually congenital, and results in a tumor, 
acquiring often great bulk. 

Arterial Tumors. — The only arterial tumor of this class is that so 
well described by John Bell, under the name of Aneurism by Anas- 
tomosis. 

The most common sites are the scalp, lip, nose, orbit, eyelid, cheek, 
and chin, but may occur in any part of the system. It is situated in 
the cellular tissue. 

This tumor consists essentially of a net-work of arteries and veins, 
closely connected together by cellular or cellulo-fibrous tissue. It 
may commence in a speck not larger than a shot, and rapidly acquire 
large size. The arteries are singularly convoluted, and, in cases of 
long standing, may acquire the caliber of a goose-quill. The coats 
of the 'arteries are thin and sacculated. The arteries around the 
tumor, to some distance, are enlarged also. The general disposition 
of the veins is similar to that of the arteries, but usually they are less 
capacious, and their circulation sluggish. The intervening cellular 



r 



« 



120 SYLLABUS. 

tissue becomes much developed, condensed, and hardened into a cel- 
lulo-fibrous consistence. The tumor has no proper envelope. In 
general, the surface of the tumor is of a reddish-scarlet hue, with 
here and there a purple spot, and so transparent as to allow many 
of the enlarged vessels to be seen through it. 

Of the causes or origin of these tumors we know little ; their 
development is commonly very slow, but sometimes rapid; as stated, 
it is usually, if not always, congenital, commencing as a nevus, or 
mother-mark. 

The tumor has generally an irregular outline, and rarely projects 
more than six or eight lines beyond the level of the surrounding 
parts. It is soft and compressible, the finger sinking into it like wet 
sponge ; but when the finger is removed, the skin regains its position. 
The color varies in different cases. When it occurs on the skin, or 
skin and cellular tissue, it is generally of a reddish hue, inclining to 
scarlet. In old cases, and when it lies beneath mucous membrane 
it is more commonly bluish or purplish. It beats and throbs syn- 
chronously with the contraction of the heart, and imparts an aneu- 
rismal thrill to the finger. 

These tumors sometimes ulcerate and slough, causing hemorrhage, 
and even death. 

The remedies recommended are excision, escharotics, strangulation, 
injections, starvation, and amputation. 

Excision. — This may be practiced best in small arterial tumors, 
before there is much development of the surrounding arteries; where, 
however, there is much pulsation in the tumor and arteries feeding it, 
we may look out for hazardous hemorrhage if excision be attempted, 
and should be prepared to meet it. 

When it is determined to extirpate the tumor, it must be done by 
cutting around, and not into the tumor. The operation must be 
done rapidly, and a good assistant at hand to compress bleeding 
arteries, till they can be tied. If there is one main artery feeding 
the tumor, it should be tied at the outset. In certain cases, as in the 
lip, face, etc., ligatures may sometimes be dispensed with, by approxi- 
mating the edges of the wound by the twisted suture. 

Small arterial tumors may often be destroyed by escharotics, of 
which the Vienna paste is among the best. The paste is kept applied 
for fifteen minutes over the whole surface, and followed by an emol- 
lient poultice ; the resulting ulcer is treated on general principles. 
When the tumor is very large, it may be attacked at several points 
at once, or in succession. The caustic should not be used where it is 
desirable to avoid an ugly scar. 



VENOUS TUMORS. 121 

Strangulation is another mode of treatment, which may be effected 
by passing one or two threaded needles through the base of the 
tumor, and then tying the ligature tightly around. These may 
include the skin, or may be passed subcutaneously. 

By starvation is meant an arrest of circulation, by tying the arte- 
ries which feed the tumor. This plan, however, has not led to satis- 
factory results. 

Injections of various kinds into the vascular tumor have been tried 
— such as nitric acid, creosote, iodine, tannin, perchloride of iron, etc. 
The fluid is introduced in small quantity with a delicate syringe. I 
have used the perchloride of iron in several cases of this kind, and 
with success. Professor Gross prefers the persulphate of iron as 
"the only really unobjectionable injection for the cure of this dis- 
ease," but why I cannot explain. The perchloride is now in general 
use. This is the mode of treatment I think safest, simplest, and most 
effectual in the majority of cases. 

Other remedies, as heated needles, the seton, compression, have 
been recommended, and may, under certain circumstances, be brought 
into play. 



Yenous Tumors. 

There is a class of tumors designated by the above term, composed 
principally of dilated veins and cellular tissue ; they are situated, for the 
most part, on the scalp, cheek, lip, and chin. The submucous cellular 
tissue of the mouth, tongue, and vulva are also occasional seats ; and 
many of these latter cases resemble very much one of the forms of 
hemorrhoidal tumor. They vary very much in magnitude. Its color 
is chiefly purple or claret, or intermixed with various shades of these. 
It is soft and spongy, diminishing under pressure. It is free from 
pulsation or sound. It is usually congenital — the growth generally, 
though not always, slow. It may go on enlarging, till, finally, inflam- 
mation, ulceration, and hemorrhage may ensue, which may be con- 
trolled easily by pressure. 

The structure of these venous tumors is almost identical with that 
of the arterial last described, except that in the one veins predomin- 
ate, and in the other, arteries. The veins, on dissection, present 
much the appearance of varicose veins in other parts of the system. 

Yenous tumors are generally best managed by excision, and, ex- 
cept in some of those of very large volume, the operation is almost 
bloodless, contrasting, in this particular, very strongly with the 
" aneurism by anastomosis." 

Where the knife is objected to, the subcutaneous injection of a few 



* 



$ 



m 



122 SYLLABUS. 

drops of a strong solution of the persulphate or perchloride of iron 
will readily cause their disappearance. They may also be safely 
relieved by strangulation with a ligature. 



DISEASES AND INJURIES OF JOINTS. 

Joints are liable to incised, punctured, lacerated, and other wounds, 
like other parts. 

Symptoms. — When a joint is penetrated, there is a discharge of 
synovial fluid, rapidly followed by great pain, tension, and swelling 
of the part, with severe constitutional disturbance. When the wound 
is large, as from gunshot or other violent cause, the system receives a 
great shock, which is evinced by pallor, feeble pulse, sinking, etc. It 
is generally some hours before reaction follows ; intense inflamma- 
tion in the part rapidly develops, and frequently of an erysipelatous 
character ; the discharge of synovial fluid increases in quantity and 
consistence, exhibiting a thick, ropy appearance ; or, if the wound be 
closed, the synovial sac becomes distended, and the parts around 
(edematous, and fluctuation is felt. 

The sensation next assumes a puriform character; the patient is 
seized with rigors; alternate heats and sweats occur; the joint be- 
comes very tense; the constitutional irritation runs exceedingly high ; 
ulceration takes place ; the integuments are perforated, and a fetid, 
purulent discharge follows; the cartilages, bones, and ligaments all 
become involved in destructive ulceration. Occasionally the inflam- 
mation and suppuration extend to the surrounding cellular tissue. 

The above description is applicable to the majority of wounds of 
large joints ; but, on the other hand, by prompt treatment, the inflam- 
mation and its consequences in many cases is prevented, the patient 
recovering in a short time, with the exception of temporory stiffness 
of the joint. 

-All wounds of large joints are, however, to be regarded as serious 
injuries, but the gunshot and lacerated are much more grave than the 
simple incised. The danger or difficulty in these cases depends upon 
the size of the joint, and the extent and kind of wound. 

Erysipelas, Pyemia, Tetanus, and Hemorrhage are frequent com- 
plications of these injuries. 

Treatment. — This is sufficiently obvious, as these wounds are to be 
treated on the same principles as others. The edges of the wound 



SPRAINS. 



123 



are to be brought accurately together; all foreign substances re- 
moved; position and absolute rest enjoined; and the antiphlogistic 
treatment strictly carried out. It is very important that air should 
be excluded from the cavity. If blood or foreign matter enter the 
joint, it must be thoroughly washed out. When the injury is such as 
to preclude the idea of healing by the first intention, we should apply 
emollient applications, etc., and treat it like any other lacerated 
wound that must suppurate. 

If suppuration take place in a closed joint, it is better at once to 
make a valvular opening and let the pus out; if pus continue to 
form aud the cartilages and bones become involved, it is better to 
make a free opening and keep a tent in. There is no possible good 
to be derived from shutting up those foul accumulations ; on the con- 
trary, remove all foul matter and dead tissues, and allow healthy in- 
flammation and granulation to do their work of reparation. Anchy- 
losis is almost a necessary consequence of this condition, but it is 
the best result we can hope for. 

Where the discharge is profuse, the joint should be washed out 
freely with a syringe charged with simple water, the chlorides, 
astringents, etc., according to the indication. Many of these cases 
have to be met by amputation, or excision of the joint. In the 
milder cases, great care must be taken to avoid anchylosis, which is 
very liable to occur. As the inflammation subsides, passive motion, 
liniments, iodine, etc. will be found the best remedies. 

Primary amputation is often called for, where the injury is exten- 
sive, and complicated by the involvement of large vessels and nerves. 
As a general rule, it may be assumed that gunshot wounds of large 
articulations of the extremities are fatal, unless amputation be re- 
sorted to promptly. Even a musket or pistol ball through the knee- 
joint usually results in an amputation soon or late, if not death. 



^ 



i 



SPRAINS. 



These are the result of a severe twist or strain of a joint, stretching 
violently, and generally lacerating more or less the ligaments. The 
ginglymoid joints, as the ankle and knee, are most liable to these 
accidents. The elbow, fingers, and toes are also liable in this way. 
The reasons are obvious why the ball-and-socket-joints suffer rarely 
from Sprains. 

Symptoms. — The pain is very sudden and acute, with nausea, faint- 
ness, and inability to move the joint. Inflammation of high grade 
rapidly ensues, with great pain, tenderness, and swelling ; sometimes 



124 SYLLABUS. 

there is rupture of small vessels, and extravasation of blood. The 
only accident with which it can be confounded is dislocation ; and 
often much care is necessary to make the diagnosis clear. 

Treatment. — The indications are — 1st. To combat inflammation. 
2d. To restore the motion of the joint. These are fulfilled by anti- 
phlogistics, sorbefacients, passive motion, exercise, etc. 

As soon as the part has been properly examined, a bandage should 
be neatly applied to give support and anticipate swelling; it must 
be placed at rest in an easy, elevated position, and splints used 
when necessary. Warm fomentations will generally be found more 
agreeable at first than cold applications, but this is always a matter 
of experiment, some constitutions requiring one and some the other. 
The warm applications may be applied by enveloping the part in 
several coverings of flannel, which is kept wet with heated hop-tea, 
sugar-of-lead water, with laudanum added, or simple hot water. If 
a piece of oil-silk is placed around the flannel, the heat and moisture 
will be retained much longer; holding the joint in hot water, or hot 
salt and water, often gives great comfort. Where the inflammation 
runs high, leeches may be applied with great benefit. 

If the warm applications are disagreeable, we may resort to the 
cold, as iced-water, cold lead-water, cold douche, etc. 

When there are constitutional symptoms, fever, sleeplessness, etc., 
they must be met by appropriate remedies. 

After the inflammation and pain subside, we must resort to lini- 
ments, frictions, cold douche, passive motion, etc. 

It is a matter of first importance not to use the joint in the acute 
stage ; even the weight of the body should not be borne on it. In 
the more chronic condition, a crutch should be resorted to, and the 
joint brought into play very gradually. Not only is lameness kept 
up for months frequently, but permanent lameness fixed on the patient 
by not preserving perfect rest in the beginning. 

SYNOVITIS. 

This affection, which is an inflammation of the synovial membrane, 
may occur in any joint, but is most common in the large articula- 
tions; it is a disease of great interest from its extreme frequency; 
from its influence over locomotion, and endless other consequences 
that result from inflammatory action. 

Synovitis may be caused by cold, the presence of articular bodies, 
mechanical violence, as sprains, blows, falls, etc. In the majority of 
cases, however, it arises from rheumatism, gout, eruptive fevers, mer- 
cury, scrofula, and syphilis. 






SYNOVITIS. 



125 



Symptoms. — These depend much upon the manner of attack and 
rapidity or acuteness with which it progresses ; there is usually 
stiffness of the joints, which is most marked in the morning, and 
gradually diminishes on exercise ; pain and tenderness on moving 
the joint or pressing it; swelling and fluctuation; pale, glossy ap- 
pearance of the skin ; inability of maintaining the extended position, 
and a sense of heat within. As the symptoms progress, the local 
ones become more acute, and the constitution sympathizes, exhibiting 
all the signs of inflammatory fever. The pain becomes very severe, 
especially at some spot, depriving the patient of sleep and ability to 
make the slightest motion of the joint. 

In some cases it comes on slowly and very insidiously; the first 
evidence being a little stiffness or weakness, with considerable en- 
largement from accumulated synovial fluid. As it goes on, after 
weeks, or even months, the symptoms become aggravated, the joint 
is much distended and weak, and the limb is wasted. 

In rheumatic synovitis, the symptoms are acute and well marked 
usually from the commencement. After fatigue and exposure to 
cold, or from some other cause, the patient may be suddenly attacked ; 
he goes to bed at night well, and by the morning has one or more 
joints affected, exhibiting redness, swelling, heat, severe pain, in- 
ability to move, and with all, decided fever. The joints most likely 
to suffer from rheumatic synovitis are the knee, ankle, wrist, and 
elbow; the hip and shoulder rarely. Other forms of rheumatism 
may be confined to the fibrous tissues outside of the joint, while this 
attacks principally the lining membrane, and exhibits all the signs of 
synovitis before described, as effusion into the joint, etc. 

The syphilitic form of this affection is one of the results of ter- 
tiary syphilis, and appears in those usually who have been broken 
down by the combined influence of syphilis and mercury. The history 
of these cases will generally determine the diagnosis. The strumous 
or scrofulous form of synovitis will be treated of elsewhere. 



ii 



Morbid Anatomy. — The appearances presented on dissection vary 
greatly in different cases, according to the degree of acuteness, cause, 
etc. In ordinary cases of simple inflammation there is increased 
vascularity in the early stages, some opacity of the affected mem- 
brane', and increase of secretion. There is also some effusion of 
lymph, with slight adhesions, perhaps, and floating flocculi; in the 
acuter cases, and a little later, the vascularity is more marked ; the 
effusion of lymph more copious, and the synovial secretion increased 



126 SYLLABUS. 

and of a dirty, viscid character. The next step is suppuration and 
ulceration, with all its sequelae. 

Suppuration, as a consequence of ordinary synovitis, is unusual ; 
it rarely occurs in the arthritic form, occasionally in the syphilitic, 
but very often in the strumous form. 

Synovitis is always a grave affection, and there is a great resem- 
blance between these inflammations and those of serous membranes. 

Treatment. — In its simple forms, synovitis must be treated on the 
general principles of inflammation; and in the specific forms of 
scrofula, syphilis, etc., it should be modified accordingly. 

Position and absolute rest of the joint are, of all things, the 
most important. If necessary, splints must be applied in young 
subjects who cannot be controlled without them. 

DROPSY OF JOINTS. 

By this term is meant a chronic accumulation of fluid in a joint, 
preceded or accompanied by little or no inflammation. It is most 
frequent in the ginglymoid joints, and particularly the knee. 

The causes may be any of those assigned for synovitis, and it is 
frequently inexplicable ; rheumatism is the most common cause ; 
gout and syphilis are occasional causes. 

Symptoms. — These are generally well marked. The joint is en- 
larged, rounded, soft, and fluctuating, and with little or no pain except 
from fatigue; there is no discoloration. The progress of the dis- 
ease is very chronic, the accumulation of fluid being usually gradual, 
but sometimes a joint may be much distended in two or three weeks. 
Its march is more rapid in gouty and rheumatic subjects, and after 
exanthematous fevers. From the symptoms and history of the case, 
the diagnosis is readily made out; but if difficulty should occur, the 
exploring needle will settle the matter. 

Morbid Anatomy. 

Prognosis, 

Treatment.— Dropsy here, like elsewhere, is a symptom, and not 
the disease ; the cause must be sought and removed. When the dis- 
ease is purely local, as from mechanical injury, sprain, etc., rest, em- 
brocations, blisters, etc., will generally relieve it. Absolute rest is 
indispensable in the treatment, and a well-applied bandage is import- 
ant to support the parts and promote absorption. 

In obstinate cases which resist all other remedies, it may become 
necessary to puncture the joint and allow the fluid to escape. The 
joint in this relaxed and torpid condition is in a very different state 



MOVABLE BODIES WITHIN JOINTS. 12t 

from a healthy joint, and inflames much less readily. There would 
be great danger of violent inflammation from puncturing a healthy 
joint; whereas there is little from puncturing a dropsical one. The 
best way of puncturing, or rather of evacuating the fluid, is to insert 
a small trocar through the skin, then carry it for an inch beneath it 
before puncturing the synovial sac, so as to make a valvular opening, 
to prevent the air from entering; the sac is then pressed steadily to 
evacuate the fluid, and when the stream is about ceasing, the trocar 
should be withdrawn ; in this way the entrance of air may be guarded 
against. An ounce or two of fluid left in the joint will soon be ab- 
sorbed; a bandage and compress should then be well applied. In 
extremely chronic and obstinate cases, injections of iodine and other 
articles have been recommended; the injection is performed in the 
same way and upon the same principles as in hydrocele. I have done 
this several times in old cases with good effect, and without any 
untoward symptom. 

MOVABLE BODIES WITHIN JOINTS. 

There are certain morbid formations met occasionally within joints 
which interfere with their functions and often give rise not only to 
inconvenience, but to great pain. 

What are termed inter-articular cartilages, or osseous concre- 
tions, are seen in different joints, but particularly in the knee, elbow, 
wrist, and jaw, the first being their favorite seat. 

The size, number, form, color, and consistence of these bodies pre- 
sent much diversity. In the knee, where they attain their largest 
size, they sometimes equal in bulk the patella or a pullet's egg, 
though commonly much smaller; their number is generally in inverse 
ratio to their volume. When large, they may be solitary; when small, 
the number may reach ten or twenty; as many as sixty have been 
found in one case. They are mostly of a whitish, grayish, or pale- 
straw color ; while their consistence ranges from that of fibro-cartilage 
to bone. Their shape also differs ; they are generally more or less 
ovoid or lenticular, and more or less flattened by pressure; some- 
times there are several united together by fibrous attachments; they 
are mainly smooth, but sometimes more or less rough, and of a spongy 
or honey-comb appearance. 

Structure. — In their earlier stages, these bodies are usually fibro- 
cartilaginous, but with time assume the character of cartilage, or even 
bone. Their mode of development has excited much discussion, and 
is yet unsettled. They are doubtless the result of plastic effusion, 



128 SYLLABUS. 

resulting from inflammatory action. The fact that they undergo 
transformations, even after they have lost their attachments, shows 
that they have a circulation and vitality. They are originally at- 
tached to the articular surface, from which they are developed, and 
we know not how and when they become detached. 

Symptoms. — These are sometimes so well marked as to leave no 
room for doubt, particularly when they occur in the knee. There 
are other cases in which a satisfactory diagnosis is impossible. As a 
general rule, where the body is large, it gives little pain ; whereas, if 
it be small, and capable of slipping about between the articular sur- 
faces, it may cause severe pain, lameness, and inflammation. The 
patient, in walking, is sometimes seized with pain, so sudden and 
violent as to compel him to sit down, to prevent falling. Even at 
night, while moving the limb in turning over, this body may be dis- 
placed, and cause an attack. 

When the foreign body gets in the habit of slipping about, it is 
certain to produce pain, more or less irritation or chronic inflamma- 
tion, with enlargement of the joint and thickening of all the tissues 
around, together with an increase of the synovial fluid. The surgeon 
can, however, by careful manipulation, detect the offending body. In 
the knee, it generally forms a marked projection on the side of the 
patella, more frequently on the external than the internal, its outline 
being distinguishable both by sight and touch. Sometimes it re- 
treats to a part of the joint where it gives no inconvenience, and the 
patient supposes it has disappeared entirely; sooner or later it comes 
from its hiding-place, and reproduces its characteristic symptoms. 
After a time, the symptoms all become aggravated, and locomotion 
is put an end to. 

Diagnosis. — The most important diagnostic signs are : the sud- 
denness with which the joint is deprived of its use, the severity of the 
pain, the ability of the surgeon to see, feel, and push about the con- 
cretion, and the facility with which the patient can usually relieve 
himself by his own efforts. The complaint is not dangerous, but 
gives much trouble, and the only relief is an operation, which is not 
free from danger, and must be conducted with great prudence. 

Treatment. — Where the foreign body gives little discomfort, it is 
best to interfere as little as possible with it — a laced cap, to prevent 
it from slipping about, and to support the joint, is all that should be 
attempted. Such cases, however, are exceptions, and more decided 
treatment is generally demanded. 

The knife is the only reliable remedy, and this is not free from 
danger, particularly when not used with skill. The great point is to 



MOVABLE BODIES WITHIN JOINTS. 129 

penetrate the joint subcutaneously, and extract the body through a 
valvular opening, so as not to allow the air to enter the articulation. 
When the operation is performed in this way, it is usually safe and 
successful. The patient should be prepared for the operation by 
rest, diet, etc. 

In the operation on the knee, which may be applied to other joints, 
the limb is extended on a table ; the foreign body is brought to the 
upper and outer part of the patella, where it is held by an assistant, 
while the surgeon introduces a long, narrow bistoury, from above 
downward, into the synovial pouch, which is then freely divided, so as 
to permit the concretion to be pushed through the opening into the 
subcutaneous cellular tissue, entirely beyond the serous lining ; the 
puncture is covered with collodion, and a compress gently bound 
upon the knee, immediately over the upper edge of the concretion, 
the object being to promote speedy union of the edges of the articular 
wound. The limb is kept quiet, and cold-water dressings applied. 
When the inner wound is healed, the extraneous substance may be 
removed by a simple incision ; or, if it is in a position to give no 
inconvenience, may be allowed to remain; being outside the joint, it 
forms attachments, remains stationary, and is harmless usually. 

Chalk-stones frequently form in the joints of gouty persons. They 
are composed of urate of soda, phosphate and carbonate of lime. 
They vary much in size, shape, and consistence, and may attack one 
or many joints. 

The only treatment for these is the constitutional treatment for 
gout — colchicum, aconite, alkalies, purging, etc. 

Fibrous Tumors are sometimes formed on the synovial membranes. 
They occur most often in the knee, and vary in size from a pea to an 
almond, or even larger. 

The term fimbriated has been applied to a peculiar growth which 
forms on the surface of the synovial membrane. It consists of innu- 
merable little bodies, of all sizes, from a millet-seed to a pea ; of a pale- 
yellowish or whitish color, and bearing a very close resemblance to 
the epiploic appendages of the large intestine. They are smooth, 
and cover the free surface of the membrane all over, being connected 
to it either by a broad base, or, more frequently, a narrow pedicle 
It is hard to make a diagnosis, and treatment is of little avail. 



130 SYLLABUS. 



TUBERCULOSIS OF JOINTS. 

Scrofulous affections of the joints are common, and may commence 
in any of the tissues in or around them. They are almost peculiar to 
children under ten years old, and are indications of strumous diathe- 
sis; the march is chronic, and soon or late involves all the tissues 
around. There are always other signs present of involvement of the 
constitution. 

The disease may select any joint for its ravages ; but we shall take 
the hip-joint as a fair type of all the class. From the importance of 
this joint, its deep seat, and magnitude, the affection here is one of great 
interest, and the diagnosis, in the early stage, is often very difficult. 

Coxalgia is the term which has been applied to strumous disease 
of this joint, and, as stated of these affections of joints generally, is 
most common in early life, particularly under ten years, and is rare 
after the age of twenty. 

I am, however, myself satisfied that many of the diseases of the hip 
which are set down to scrofula have no connection with it, but are 
the result of mechanical injury, from falls, leaping, etc. It is, as 
stated by authors generally, most common in boys, the class most 
exposed to injuries, and it is not uncommon to see coxalgia, where in 
the beginning there is no evidence of scrofulous diathesis, or of de- 
rangement of health in any way. There is no doubt that injuries 
may act as exciting causes where there is a predisposition, and 
develop disease that otherwise would have remained dormant — cold, 
damp, badly-ventilated apartments, bad diet, mercury; in short, all 
those causes which have a tendency to debilitate or to derange the 
general health may act as causes for the development of these affec- 
tions of the joints, whether scrofulous or not. 

Symptoms. — These are very obscure in the early stage, and the 
disease, in its formation, is often mistaken for others. The first 
symptom usually is a sense of fatigue or weariness in the limb, with 
a dragging motion, pain in the knee, and liability to trip in walking. 
The symptoms may vary little for several weeks, or even months ; after 
an indefinite time, however, they are aggravated, the lameness is more 
marked, and the sleep is disturbed by twitching in the extremity. It 
is a very remarkable fact that the pain, in the early stage, is almost 
always referred to the knee, and particularly its inner side, although 
there is no great uniformity in this. It is always increased by exer- 
cise, and is usually worse at night and in damp weather. On examin- 
ing the knee, there is no tenderness or mark of inflammation, free 



TUBERCULOSIS OF JOINTS. 131 

handling and motion being borne with impunity. The pain is often 
of neuralgic character, being very irregular or intermittent. 

The pain soon diverges from this point, and is felt in the leg and 
thigh, without any fixed habitation. No satisfactory explanation has 
been given of this pain in the knee. 

After a time, which varies according to the rapidity of progress, 
the principal pain is transferred to the hip and its vicinity, the point 
or points here not being constant. Pressure and percussion, as well 
as rude motions or twisting, increase the pain. 

The next phase shows a marked aggravation of symptoms. There 
is great increase of the pain in hip and knee, flattening of the but- 
tock, effacement of the gluteo-femoral crease, and apparent elongation 
of the limb, with twitching and wasting of the muscles ; the pain and 
restlessness at night become very distressing ; the general health, 
digestion, etc. become much impaired ; high irritative fever is devel- 
oped, and the patient rapidly emaciates. 

The local symptoms, so obscure in the early stage, now become 
well developed : the buttock is greatly flattened — it is much broader 
as well as larger than the sound side ; the gluteal muscles are soft 
and flabby, and skin loose; the gluteal crease is entirely effaced; the 
muscles of the thigh and leg are much wasted. 

A prominent symptom now is elongation of the limb, and is almost 
pathognomonic ; it varies from half to an inch and a half, and is ob- 
servable standing or lying. The explanation of this elongation is 
not easy, but is supposed by some to depend on excess of synovial 
fluid ; but the most probable cause is a difference in the level of the 
hips, owing to the active use of the muscles on the sound side, while 
on the other they are relaxed and enfeebled; there is, therefore, no 
real elongation of the limb — it is only apparent. 

Finally, in this stage there is generally a marked depression in the 
lumbar region, with a slight inclination of this part of the spine 
toward the sound side, and an unusual prominence of the abdomen. 

In the last stage of this affection the symptoms reach a point which 
puts at rest all doubts, if any should still linger, as to its character. 
Matter is now formed, and its presence is indicated by increase of 
pain, throbbing and tension, increased swelling of the gluteal region, 
which is most prominent over the articulation ; by oedema and en- 
largement of the superficial veins; the joint cannot bear the slightest 
pressure or motion; the constitution suffers, and there are rigors, 
high fever, and copious sweats. In some rare cases, the abscess forms 
in a quiet way, with little general disturbance. 

Fluctuation becomes distinct as the matter approaches the surface. 



132 SYLLABUS. 

It may point in various directions about the gluteal region, near the 
joint, or at some distance off — sometimes in the groin or low down 
on the thigh ; there may be one or a dozen openings, some of which 
are long and tortuous. In rare cases, the matter may work through 
the acetabulum and discharge into the pelvis, and escape through or 
beside the rectum or vagina. The pus discharged is of that peculiar, 
unhealthy character usually which belongs to scrofula, and often has 
mixed with it portions of the broken-down tissues, as cartilages, 
bone, etc. The pus is fetid, as is the case in bone affections gener- 
ally in the commencement. 

The suppuration is sometimes profuse and exceedingly debilitating, 
at others sparing, and it varies greatly, from time to time, in the same 
case, continuing for months or years. When it is very chronic, the 
evidence is strong that there is caries or necrosis of the bone pres- 
ent. In many cases the patient is worn out by hectic, the constant 
drain, and suffering. 

Suppuration does not occur, or at least only to a very limited ex- 
tent, in some cases, which leaves behind great deformity. 

The abscess, there is reason to believe, usually commences in the 
joint, though it may be attacked secondarily. 

After suppuration has been fully established in the joint, and the 
matter discharged, very striking and characteristic changes in the 
parts follow. The limb now really becomes shorter, is much wasted 
and disfigured, the heel being considerably elevated, and the toes only 
touching the floor when the patient stands. The degree of shortening 
varies to the extent of several inches, but is often more apparent than 
real, from distortion of the pelvis. The position of the foot is vari- 
able, sometimes looking forward, most commonly outward or inward, 
and by far the most frequent position is the latter. All this depends 
upon the extent and direction of the ravages committed around the 
joint. When the acetabulum is destroyed, and the head and neck of 
the femur is entire, the foot turns in, as in dislocation upward ; and 
when the head and neck are destroyed, the foot turns out, as in frac- 
ture of the neck. The thigh is generally more or less flexed on the 
pelvis, and is directed inward toward the other limb ; in rare cases it 
stands out in the opposite direction. 

The thigh is always in a very rigid state, owing to contraction of 
the muscles and thickening of the surrounding tissues. The thigh 
cannot be abducted or carried backward, on account of the extreme 
tension of the muscles. The leg is usually flexed on the thigh, from 
contraction of the ham-string muscles. 

The position of the trochanter is directly over the acetabulum, or 



ANCHYLOSIS. 133 

near it, and the head and neck are usually removed by the disease. 
Luxation of the bone, however, is extremely rare, the shortening 
being attributable to the destruction of the head of the neck alone. 

Diagnosis. 

Morbid anatomy. 

Prognosis. 

Treatment. — This depends much upon the stage and the condition 
of the constitution. In those cases of scrofulous character, little is 
to be expected from local remedies, and our attention, therefore, must 
be directed to the constitutional symptoms. 

In every stage, and under all circumstances, absolute and uncon- 
ditional rest must be insisted on ; without this, all treatment is use- 
less. The recumbent position must be continued for months, as one 
minute's motion of the joint may undo all the good done by pro- 
tracted rest. 

In the early inflammatory stage, leeches, cups, blisters, etc. must 
be employed; poultices often afford much relief; occasional purg- 
ing is also well ; anodynes are often indispensable. 

In delicate senemic frames, a tonic course must be adopted. 

Most surgeons insist not only on the recumbent position, but on 
splints so contrived as to render the hip-joint immovable. As for 
issues, repeated blisters, etc. in the latter stages, they are to my mind 
worse than useless. 

After suppuration is fairly established, and destructive ulceration 
is going on, it becomes a question whether free incision should not 
be made, the broken-down fragments of bone, cartilage, etc. removed, 
and a better chance allowed the part for healthy granulations. I am 
a decided advocate for this practice. 

ANCHYLOSIS. 

By this term is meant a stiff or motionless condition of a joint, 
which is usually the result of inflammatory disease. It is character- 
ized by the terms complete or incomplete, according to the presence 
or absence of slight motion. There is also false anchylosis, when 
the motion is destroyed, not by disease of the joint itself, but the 
tissues around, as in extensive burns, etc., involving the skin and 
cellular tissue. 

All the causes which have been spojien of, productive of inflamma- 
tion, and many others, as fractures, etc., may leud to anchylosis. Dis- 
ease alone of a joint may produce it, In intra-articular anchylosis, 
the first step is effusion of lymph, which becomes changed, first into 

10 



134 SYLLABUS. 

fibrous or cellulo-fibrous tissue, then into cartilage, and finally into 
bone, which unites the ends of the bones of the articulation so firmly 
as to put an end to all motion. When a joint is rendered motionless 
by the internal deposition of plastic matter, ossification almost inva- 
riably follows, soon or late. The adhesions alluded to vary greatly 
in extent — in some instances constituting only a few detached bands, 
the remainder of the synovial membrane being sound ; in such cases 
the adhesions may be broken up, and the joint regain its function. 
These bands or adhesions may be extended indefinitely to many or 
all parts of the joint, and in the worst cases ossification follows. 

Treatment. — The use of sorbefacients, frictions, and passive mo- 
tion is generally sufficient to relieve the milder cases. 

Where these fibrous bands exist, all inflammation has disappeared, 
and slight mobility still remains in a joint, we may often succeed by 
placing the patient under chloroform, and breaking up the adhesions 
by forcible flexion and extension of the joint. A certain amount of 
inflammatory action usually results from such efforts, and it must be 
promptly met by antiphlogistics. 

In some cases they are best managed by mechanical apparatus, 
which makes gradual extension of the joint. 

When the force used is too great the bones are sometimes fractured, 
and under any circumstances, after these forcible attempts, violent 
and even fatal symptoms may follow. When we have reason to expect 
anchylosis, we should place the limb in the position which would be 
most useful ; the arm should be flexed and the leg straight for obvious 
reasons. 

In cases of firm, bony anchylosis, when the limb has been flexed in 
a position to be useless, operations for relief have been performed by 
dividing or removing a portion of bone, and then placing the limb 
in proper position, and retaining it there till the parts have healed. 

DISLOCATIONS. 

A dislocation is the displacement of one articular surface from 
another. It is usually the result of external violence, and is accom- 
panied by laceration of the connecting ligaments. 

Importance of a thorough knowledge of the subject to the young 
surgeon. 

As every joint is composed of at least two bones, the question 
arises, when the accident occurs, which is the dislocated bone? Cus- 
tom has established among surgeons, that the bone nearest the body 



DISLOCATIONS. 135 

is to be regarded as the fixed bone, and the one farthest off as the 
luxated one. 

They are divided into simple and complicated or compound, com- 
plete and incomplete, primitive and consecutive, recent and old, 
and congenital. 

Definitions of each. 

The ball and socket joints, or those which have most freedom of 
motion, are most liable to luxations, as the shoulder and hip. 

Causes of Dislocations. — Yiolence ; muscular contraction. 

Dislocations may occur at any period of life, but are more frequent 
in the middle periods and in old persons, than in childhood and youth. 

There are many symptoms common to nearly all dislocations, as 
loss of function, deformity, change in the length and axis of the limb, 
numbness, swelling, pain, etc.; but these are best considered in con- 
nection with particular dislocations. 

Morbid Anatomy. — The head of the bone, on dissection after recent 
injuries, will be found displaced to a greater or less extent, and in 
very different directions. The ligaments are more or less lacerated ; 
the displaced head rests upon some of the tissues on the outside of 
the joint, which is generally occupied by blood, fluid or coagulated. 
The muscles are stretched, and sometimes lacerated. The nerves 
also are sometimes displaced or pressed upon; so, also, with the 
blood-vessels. If examined some days after the accident, all the 
marks of inflammation, in some stage, will be found. 

Treatment. — The indications in simple luxation, are : 1st. Reduc- 
tion of the bone. 2d. Absolute rest till the ligaments have time to 
unite. 3d. To combat inflammation. 4th. To restore the functions. 

In reducing a dislocation, we should bear in mind the forces which 
oppose us, viz., the firm contraction of muscles, the ligaments, and 
prominences of bones. Too much importance, no doubt, has been 
attached to the muscular resistance alone, as great difficulty often 
remains after the muscles are fully relaxed. 

The mechanical means used, as well as the constitutional, will be 
explained in the treatment of individual cases. 

Complicated luxations are those in which the displacement is 
accompanied by fracture, the rupture of an important nerve or blood- 
vessel, a violent contusion or wound extending deeply into the sur- 
rounding tissues, or even into the joint; one or several of these 
lesions may exist at the same time. Such injuries are most frequent 
in the elbow, wrist, knee, and ankle, for the reason that they are least 
protected and most likely to receive violence. 



136 SYLLABUS. 

The symptoms of such cases are usually very obvious, and if you 
recollect the remarks we have already made on wounds of joints, you 
will readily comprehend their gravity. A complicated luxation is 
always a serious injury, liable to be followed by most violent symp- 
toms, and not unfrequently death. Inflammation, erysipelas, abscesses, 
pyemia, etc., are frequent consequences. 

Treatment. — The parts should be reduced and dressed, on the 
common plan of wounds, as soon as possible, by plasters, stitches, 
bandages, position, etc. All loose bone must be removed. When 
the end of a bone protrudes through a small wound in the skin, and 
cannot be reduced, the opening must be enlarged. If the end of the 
bone is sharp, or denuded of periosteum, it must be cut off by the saw 
or pliers. Chloroform is of great use in these cases. 

If the luxation is complicated with fracture, it must be reduced as 
soon as possible, before adjusting the fracture. Splints of course 
should be used where applicable. 

After-treatment. 

Amputation and resection. 

Chronic, Old, or Neglected Dislocations. 

These are very embarrassing cases, as it is not only difficult, but 
often impossible, to say after what lapse of time it may be prudent or 
safe to attempt reduction. 

Anatomical changes which occur in these cases. 

Manner of attempting reduction; preliminary steps. 

Danger of rupturing arteries, nerves, etc. 

Particular Dislocations. 

Lower Jaw. — From the form of this joint, dislocation can only 
occur forward and downward, the condyle slipping into the zygo- 
matic fossa. It usually happens on both sides in consequence of 
yawning, gaping, vomiting, convulsions, etc., but may occur on one 
side only, and from mechanical violence applied to the chin, particu- 
larly when the mouth is open. 

Symptoms. — Mouth is wide open, and cannot be closed ; the chin 
is advanced ; the condyle is found in advance of its natural cavity, 
which will be found void. 

The reduction is generally easily effected by the thumbs, covered 
with a thick glove, or towel, to prevent being bitten; and, with the 
aid of chloroform, is usually quite easy; the chin is drawn up with 
the fingers, while the thumb presses down. 

It is easily thrown out again, and the patient should be watchful. 



DISLOCATIONS. 13 f 

Dislocation of the clavicle is rare, compared to fracture. 

The sternal extremity may be dislocated forward, backward, and 
upward; downward, impossible. 

Symptoms of each. 

The reduction is easily effected, but it is so difficult to maintain it 
in situ, that deformity is always the consequence. Firm ligamentous 
union, however, takes place, and the motions and strength of the arm 
are well preserved. 

Treatment. — A wedge-shaped pad is placed in the axilla, a stout 
compress over the head of the bone ; the elbow supported in a sling, 
and the arm well bound to the side. 

The scapuloclavicular extremity is firmly articulated to the inner 
margin of the acromion process of scapula, and can only be torn 
loose by a direct blow on one or the other bone, or indirectly through 
the arm or sternum. 

This dislocation may occur in three directions : upward, above the 
acromion; downward and backward, beneath this process; and, 
downward and forward, under the coracoid process. The first is 
far the most common. 

Symptoms are 

The reduction is easily accomplished, but the same difficulty in the 
treatment, from the extreme mobility of the parts, occurs in this as 
the dislocations at the inner extremity. 

Treatment of these is by the same apparatus as that described for 
dislocations of the other extremity, or for fractures of the clavicle. 

Dislocations of the Spine. 
Symptoms and treatment. 

Dislocation of Ribs. — Extremely rare at the costo-vertebral articu- 
lation, as might be expected from the mode of attachment and pro- 
tection. 

Impossible to make a satisfactory diagnosis. 

The rib is sometimes, by violent blows, knocked loose from its car- 
tilage, or the latter from its attachment to the sternum. 

The treatment is a simple bandage, and attention to the contusion 
and other symptoms. 

Dislocations of any of the phalanges of the fingers, or metacarpal 
bones, may occur ; but we will not detain you with these, as they rarely 
give much trouble, and the treatment is obvious on general principles. 



138 SYLLABUS. 

Dislocation of Wrist. — The dislocation of this articulation is so 
rare, that a surgeon of no less reputation than Dupuytren denied the 
possibility of its occurrence. Since his day, however, it has been 
clearly proven that this accident does happen. The mode of articu- 
lation of the radius, with the scaphoid, semilunar, and cuneiform 
bones, is such, and the ligaments so strong, that the lower end of the 
radius gives way when violence is applied, and is fractured before 
dislocation can occur in most cases. 

The carpal bones may be displaced from the radius and ulna back- 
ward or forward ; luxation laterally cannot occur without fracture. 

An ignorant surgeon may mistake these dislocations for fracture, 
but the injury is so well marked, that a careful common-sense exam- 
ination will suffice to guard against this error. The deformity in 
dislocation is much greater than in fracture. 

The reduction is easy, gentle extension and counter-extension 
being sufficient. A splint on the palmar surface, and bandage, with 
cooling lotions, and proper attention to the motion of the joint, meet 
the indications. 

Radio-ulnar Joints. — The ulna may be thrown forward or back- 
ward, beyond the line of the radius. Both are very rare, except as 
an accompaniment to fracture of the lower extremity of the radius. 

Dislocation backward of ulna, is usually the result of violence 
applied to the hand or forearm during pronation, from sudden twist 
or wrench. The signs are characteristic : the hand is in a fixed state 
of pronation, and inclined toward its inner margin ; the head of ulna 
is directed obliquely across the radius, and forms a distinct eminence 
above the cuneiform bone ; the lower extremity of arm looks unnatu- 
rally narrow. The reduction is made by flexing the forearm at right 
angles with the elbow, and then making firm extension and rotating 
it outward. 

The symptoms of dislocation forward are the reverse of the one 
just described. The reduction is effected in the same way. 

A splint and bandage are required, with great care, in combating 
inflammation. 

Dislocation of the Superior Radio-ulnar Joint may occur in three 
directions, the head of the radius being thrown from the sigmoid 
cavity of the ulna forward, backward, or outward, the frequency of 
each being in the above order. 

The most common causes of dislocation forward, are falls on the 
palm of the hand. 



DISLOCATIONS. 139 

The symptoms are well marked. There is a vacuity at the natural 
position of the head of the radius, which can be felt in its new posi- 
tion in front of the elbow, rolling about under the finger, upon rotat- 
ing the hand. The forearm, slightly flexed, is in a state midway 
between pronation and supination, and all attempts to straighten or 
bend it are unavailing. When an effort is made to flex the arm sud- 
denly, the head of the radius is felt to strike against the humerus, 
which is very characteristic of the nature of the accident. 

The reduction is easily accomplished. An assistant seizes the arm 
at its middle, to make counter-extension ; another seizes the hand on 
which extension is made in the semiflexed direction, to relax the 
biceps muscle. The extension is then made, and the head of the 
bone is pushed in place, while supination is made ; the head thus 
easily slips in place. 

The dislocation backward and outward is uncommon, but easily 
detected, if you bear in mind the natural position of the bones. 
The head of the bone is found to be in its unnatural position, and 
the reduction is then effected by extension, and pressing the bone 
in place with the fingers. 

After once occurring, these accidents are exceedingly liable to take 
place again on slight provocation ; it is, therefore, important to band- 
age the arm well, apply compresses, so as to keep the bone in place, 
and to maintain the parts at rest till time has been given for union of 
the ligaments — at least two weeks. 

Dislocations of Elbow. — These are among the most important 
subjects that can command the attention of the surgeon — from their 
frequency, their complications, difficulty of diagnosis, and danger of 
permanent deformity and loss of motion. They are generally worse 
understood and treated than any luxations in the whole body, and 
this should satisfy you of the importance of understanding thoroughly 
the anatomy of this joint. 

The dislocation of the bones of the forearm at the elbow, upward 
and backward, in contact with the posterior surface of the humerus, 
is the most common. Displacement of these bones forward is very 
rare, and cannot well take place -without fracture of the olecranon 
process. 

Lateral displacement of these bones is also very rare, and always 
incomplete, from the great breadth of the articulation, and strength 
of the ligaments and muscles. We have already spoken of the head 
of the radius alone. The ulna may also be dislocated alone, upward 
and backward. 



140 SYLLABUS. 

Dislocation of both bones backward is usually the result of a fall, 
the patient receiving his weight on the extended hand and arm. The 
ligaments are thus ruptured, and the radius and ulna driven back- 
ward and upward behind the humerus. 

The symptoms are well marked, when not complicated with frac- 
ture. The limb is semiflexed, and there is great deformity at the 
elbow. There is a great projection behind formed by the olecranon, 
and in front a large tumor, formed by the condyles of the humerus. 
The forearm is fixed in a semiflexed position, and any attempt to move 
it is painful and unsuccessful. The fingers are flexed, and the dis- 
tance between the elbow and wrist diminished at least an inch in 
front. The muscles in front of the joint, biceps, and brachial are 
stretched over the condyles, while the triceps behind is thrown back, 
and stands out boldly from the humerus, forming one of the most 
conspicuous signs of the accident. 

In rare cases, the arm is straight instead of semiflexed, and more 
movable. 

Where there is much swelling, before the examination, or fracture, 
the diagnosis is sometimes far from being easy. Where there is 
fracture of the humerus just above the condyles, the contour pre- 
sented greatly resemble in the two injuries. In dislocation, however, 
the parts are fixed, while in this fracture they are movable ; and the 
deformity in fracture is easily removed by extension, though it returns 
when it is withheld. In dislocation, too, there is actual shortening 
of the forearm, while in fracture there is none. Crepitation is always 
obvious, too, in fracture. It cannot be confounded with fracture of 
the olecranon or neck of the radius. 

The reduction is very easy at first, but difficult, or even impossible, 
after the lapse of time — even after one or two weeks it is sometimes 
impossible. The reduction may be well done by placing the heel in 
the bend of the arm and making traction on the hand, the leg passing 
across the chest ; the arm is gradually flexed as traction is made. If 
necessary, the surgeon may increase the extending force, by a towel 
bound to the wrist and passed over the back of his neck. 

The reduction may be well done by letting the patient sit in a 
chair, and bending the arm across the knee ; or the arm may be bent 
around a bedpost, the principle in each being the same. 

Chloroform or ether should be used, and, in cases of long standing, 
pulleys may be necessary. 

It has been proposed, even in bad cases, to divide the existing 
tendons, but this is a dangerous procedure, from the complicated 
anatomy. 



DISLOCATIONS. 141 

The after-treatment is of great importance ; the arm should be 
carefully bandaged and supported by one or more angular splints. 
The wire-splint is best, because it is light, cool, and allows the free 
use of cold water. To prevent anchylosis, it is very important to 
resort to passive motion gently after the inflammation sudsides. 

Dislocation of the Radius and Ulna forward is extremely rare, 
particularly without fracture of the olecranon, but instances do 
occur. 

The signs are characteristic. The forearm is shortened or length- 
ened, according as the olecranon is thrown entirely above the articu- 
lating surface of the humerus or not. The forearm is slightly flexed, 
but may be moved without force, even backward. The end of the 
humerus is felt behind, and a depression where the olecranon should 
be. The reduction is easily made by extension and counter-exten- 
sion, with well-directed pressure on the ends of the displaced bones. 

Treatment the same as in the last-named injury. 

The dislocations outward and inward, which are always partial, 
are easily detected and reduced. 

Dislocation of the Ulna alone backward is rare, and cannot 
well occur without fracture of the coronoid process. The signs, 
reduction, and treatment are all plain. 

There is a dislocation described in which the two bones are thrown 
in different directions — the ulna backward and radius forward. 

Compound Dislocations of the Elbow are extremely grave injuries, 
always giving great trouble, and generally demanding amputation. 

Dislocations of the Shoulder. — These are the most common of all 
dislocations, and, therefore, important to know well. 

They are very rare under the age of fifteen, and increase with age 
up to about sixty, after which they become less frequent. 

There has been needless ingenuity displayed on the nomenclature 
of these injuries; but there are in reality but three displacements 
worthy of remembrance, the others being mere modifications of these. 
These are the axillary, thoracic, and scapular. In the first, the 
head of the bone is thrown down into the axilla, below the glenoid 
cavity ; the second, below the clavicle, on the ribs ; and in the third, 
the head of the humerus rests on the scapula, below its spine. To 
these may be added, as varieties of the first two luxations, those cases 
in which the head of the bone has been found in the subscapular fossa 



142 SYLLABUS. 

and upon the anterior part of the neck of the scapula, below the cora- 
coid process. 

Dislocation into the axilla is far the most common, and may be 
produced by violence, applied in various ways, direct or indirect, and 
occasionally by simple muscular contraction. 

In this injury the head of the bone is found in the axilla, just below 
the glenoid cavity, lying on the inferior border of the scapula, be- 
tween the subscapular muscle and long head of the triceps. The 
axillary nerves and vessels are somewhat pressed upon, the capsular 
ligament freely lacerated below, and the articular muscles usually 
more or less lacerated. 

Symptoms. — Great prominence of acromion, which is sharp, and 
distinctly felt, with a marked depression beneath ; the shoulder is 
flattened, and the head of the bone is prominent in the axilla — easily 
felt, particularly on rotating the arm ; the elbow stands out from the 
side, and the arm is lengthened ; the fingers are numbed, and the arm 
is rigidly fixed in its unnatural position, not admitting of much motion 
in any direction, particularly inward, or outward, or upward. If 
the patient can carry his arm across the chest and place the fingers 
of the injured arm on the opposite shoulder, there can be no disloca- 
tion. This is important to remember. 

Reduction. — This is, in recent cases, generally easily effected, by 
placing the heel upon a pad in the axilla, and making extension from 
the forearm. If necessary, the power may be increased by passing a 
long towel or piece of domestic over the neck of the operator, and 
binding the ends either to the arm above the elbow or to the wrist. 
After making firm extension for some minutes, and finding the mus- 
cles to yield, the elbow should be carried toward the chest, in order 
to raise the head of the humerus from its bed. The patient should, 
in this method, be laid on his back on a sofa, or along the edge of a 
bed, with one pillow under the head. 

Where not much resistance is anticipated, reduction may be effected 
in the sitting posture by using the knee as a fulcrum, the foot being 
placed on the chair, and the humerus made to act as a lever over the 
knee in the axilla. 

Mr. White, of Manchester, laid the patient on his back, put one 
hand upon the shoulder, to fix the scapula firmly by pressing it down, 
while he raised the arm directly upward and outward. This plan has 
been revived by Malgaigne. The surgeon makes extension while he 
raises the arm. 

In some old cases, where protracted and powerful extension is 
required, the pulleys may be advantageously employed, but it should 



DISLOCATIONS. 143 

be done with great caution, for fear of rupturing important parts, as 
has been too often done. 

The Thoracic, or Subclavicular Dislocation, is comparatively 
rare. The bone, most commonly by direct violence, is thrown to the 
sternal side of the coracoid process, just below the clavicle, its head 
resting against the second and third ribs, beneath the pectoral mus- 
cles. There is considerable laceration of the capsule, and usually 
more or less injury to the subscapular, infra-spinatus, and teres minor 
muscles, all of which are attached around the head of the humerus. 

The symptoms are usually well marked. They are much the same 
as the dislocation into the axilla, except that the head of the bone is 
distinctly felt beneath the pectoral muscles, just below the clavicle, 
and its presence is made more distinct by communicating motion to 
it through the arm ; and it differs also in the position of the arm, the 
elbow being directed backward as well as outward. The limb is 
shortened from half an inch to an inch. 

The reduction is effected as in the last case, except that the 
extending force should be somewhat backward in the direction of 
the bone. 

Dislocation on the scapula, backward, is very rare. The head of 
the bone is thrown on the dorsum of the scapula, below its spine. 

Symptoms. — Shoulder flattened ; acromium prominent; arm short- 
ened one or two inches ; forearm strongly rotated inward, and bent 
obliquely across the chest ; head of bone absent from axilla, and 
plainly felt on scapula ; supination of limb impossible, and all motions 
painful and difficult. 

Reduction is effected as in the above cases, by the heel in the 
axilla, bearing in mind to make extension in the direction of the 
bone. 

The diagnosis of luxations of the shoulder is usually easy, but not 
in all cases. Simple contusion, with considerable swelling, may em- 
barrass the surgeon. Under such circumstances, the presence of the 
bone in the glenoid cavity, the rotundity of the shoulder, and the arm 
retaining its proper length, will be "sufficient. 

Perplexity may arise where there is fracture of the acromion, the 
neck of scapula, or neck of humerus, and the surgeon cannot be too 
cautious in giving his opinion. 

There are three symptoms, however, if borne in mind, will always 
protect against mistake in all these cases, viz., unnatural mobility of 
the parts, crepitation and facility of reduction, followed by imme- 



144 SYLLABUS. 

diate recurrence of the symptoms as soon as extension is withdrawn. 
In dislocation the above signs are all absent ; the bone is difficult to 
reduce, and when reduced, remains in its normal position. 

In fracture of the acromion, the arm sinks, the shoulder looks flat- 
tened, but the deformity is at once removed by simply pushing the 
humerus up by placing the hand under the elbow. 

When the neck of the scapula is fractured, which is very rare, the 
acromion retains its position, but is too prominent ; the arm is elon- 
gated, and crepitation is easily produced by raising the elbow, which 
restores also the form of the joint. 

In fracture of neck of the humerus, the head is found in its proper 
position, while the rough, angular end of the shaft is drawn into the 
axilla by the pectoral and latissimus dorsi muscles. Crepitation is 
felt, and the acromion is in its true position ; the shoulder is not flat- 
tened, and the arm is shortened. 

Double dislocation. 

After-treatment. — Little motion allowed for a month. 

Liability to recurrence. 

Chronic Dislocations. — How long after a dislocation of the humerus 
may reduction be attempted ? This is a difficult question, and no 
absolute rule can be laid down. 

Dislocations of the Foot. — Yarious dislocations of the toes, meta- 
tarsal, and tarsal bones, may occur ; they are rare without complica- 
tions, and must be treated on the plain general principles already 
laid down. 

Dislocations of Ankle. — The injuries of this joint are important 
from their frequency, their consequences, and difficulty of diagnosis ; 
displacement rarely takes place in any direction without fracture, so 
powerful are the attachments which bind the bones together. 

The ankle-joint may be dislocated in four directions, the foot being 
thrown forward, backward, inward, or outward. 

The symptoms of the dislocations forward and backward are so 
well marked as not to require description, and by flexing the leg to 
relax the gastrocnemei muscles, the reduction is generally made with- 
out difficulty; in extreme cases it may be necessary to divide the 
tendo-achillis, where the injury is of some standing. 

Luxation inward is not so common as that outward, and is almost 
always accompanied by fracture of the internal malleolus. 

Luxation outward is the most frequent, being produced by a sud- 



DISLOCATIONS. 145 

•den twist or other violence. The lower end of the fibula is always 
broken in this injury, and not unfrequently the inner malleolus is 
fractured at the same time. The symptoms of this injury are unmis- 
takable ; the internal malleolus is thrown inward, forming a remark- 
able projection under the integuments; the foot has a twisted appear- 
ance, and is easily rotated on its axis, its inner border resting on the 
ground; a considerable depression exists on the outward surface of 
the leg, a short distance above the joint, corresponding with the 
point of fracture of the fibula, and the astragalus can be felt below 
the external malleolus. 

If proper regard be paid to the structure of the joint, all these 
injuries may be readily detected ; the reduction is generally easy, and 
they are to be treated by bandages, splints, antiphlogistics, etc. 
Under the best treatment, stiffness or deformity may ensue, and the 
recovery is always very slow, requiring often many months. The 
treatment must be prompt and active. 

Compound dislocations of the ankle are exceedingly grave inju- 
ries, often requiring amputation. 

All these injuries will be fully explained in my lectures. 

Dislocation of the Patella. — This can only occur outward and 
inward, and may be complete or incomplete. Another luxation has 
been noticed, viz., the vertical, in which it is placed edgewise; they 
are all very uncommon. The one outward is most common. 

The signs of these dislocations are so obvious as to need no 
description, and the reduction of the first two is easy, but sometimes 
very difficult in the third. Cases do occur also, in which great dif- 
ficulty attends the reduction of the first two, particularly when not 
attended to immediately. 

Dislocations of the Knee. — Owing to the breadth of the articulat- 
ing surfaces and the strength of the ligaments, these accidents are 
rare. Luxation of the tibia may take place in four directions, for- 
ward, backward, inward, and outward. The last two are most 
common and always incomplete. Those forward and backward are 
also most commonly incomplete, but not always. 

The extremities of the bones are so broad, and the signs of all 
these dislocations so evident, that it is useless to waste time in 
describing them; the sight and touch reveal their true nature at 
once. There is always considerable injury done to the soft parts, 
and the after consequences are likely to be serious; under any cir- 
cumstances there must be very extensive laceration of ligaments and 



146 SYLLABUS. 

tendons, followed by high inflammation, which has to be combated 
by the rules laid down in injuries of the joints. Where the disloca- 
tion is compound, amputation is nearly always demanded. 

Dislocation of the Semilunar Cartilages. — These bodies are sub- 
ject to a displacement known under the name of subluxation, and is 
most commonly seen in those of debilitated, relaxed system, and 
particularly after chronic affections of the joint. A sudden twist, or 
awkward trip, are the most common causes. The lesion consists in 
the partial removal of the semilunar cartilages from their natural 
position, allowing them to become wedged in between the tibia and 
femur, in consequence of the relaxed condition of the ligamentous 
connections. Occasionally, where the violence is great, some of these 
connections are torn loose. 

The symptoms are usually well marked. The patient is at once 
conscious that some injury has occurred within the joint, and feels 
faint; the pain is excruciating; the limb cannot be extended, and he 
is compelled to sit or lie down. If the joint is examined immediately, 
no change is detected, and the surgeon may conclude it is only a 
strain ; inflammation soon occurs, with swelling, and effusion into 
the joiut. The pain and shock are due to the change of position of 
the cartilages which are pressed upon, and the strain on the liga- 
ments. After occurring once, it is very liable to reappear from 
slight provocation, and the patient should always be on his guard. 

The reduction is very painful, and should not be attempted with- 
out chloroform. The patient should be in the recumbent posture, 
and the thigh well flexed on the pelvis. The surgeon, placing his 
arm behind the bend of the knee and grasping the limb just above 
the ankle, bends the knee suddenly and forcibly, and then rapidly 
extends it, at the same time giving a motion of rotation to the leg. 
The limb should be bandaged and kept quiet for some days, and cold 
lotions applied, after which a laced cap should be worn. 

Dislocations of the Hip-Joint. — These are much less frequent than 
similar injuries of the shoulder; the reasons for which are obvious. 
The socket of the bone is deep, the attachments and coverings strong, 
and violence is less frequently communicated to the thigh-bone than 
the humerus. 

Age exerts a very marked influence over these accidents. They 
are rare in children, in whom the tissues are all more elastic than in 
adults, and in whom, from imperfect ossification, the epiphyses are 
more likely to give way before dislocation would occur. In old age, 



DISLOCATIONS. 141 

too, these dislocations are rare, as the violence generally results in 
fracture from the brittleness of the bones. After the age of fifty-five, 
fracture of the neck or upper part of the shaft of the femur is more 
likely to occur than luxation. It is most common between twenty- 
five and forty-five ; cases have occurred as early as from three to five 
years. The head of the femur may be displaced in four directions : 
upward on the dorsum of the ilium; backward into the sciatic 
notch; downward into the thyroid foramen; and forward on the 
pubes ; and in frequency they occur in the above order. There are 
some other anomalous dislocations which will be noticed, but they 
are extremely rare. 

Causes. 

In all these dislocations there is great injury done to the ligaments 
of the joint and the rotator muscles. There is also frequently much 
contusion around, effusion of blood, swelling, and inflammation. In 
the dislocation upward and backward on the dorsum of the ilium, 
the head of the femur rests in the fossa and lies on the gluteus mini- 
mus muscle ; in some cases it is thrown more forward. 

The symptoms are well marked. The hip is deformed, being more 
prominent than naturally; the trochanter major is carried upward 
and inward, nearer to the superior spinous process of the ilium. The 
head of the bone can be felt in thin subjects in its new position, and 
may be made to rotate under the finger. The limb is shortened from 
an inch and a half to two and a half inches ; the foot is strongly in- 
clined inward, the big toe pointing toward the opposite instep ; the 
knee is a little above and in advance of the sound one when the 
patient stands, and resists any attempt to turn it out; the thigh is 
slightly flexed on the pelvis, and may be carried across the sound 
one ; the leg is flexed on the thigh and the heel elevated from the 
floor. The limb is firmly fixed in its position, and cannot be restored 
to its proper length without reducing the luxation, and can only be 
moved a little inward. In the recumbent posture the position of the 
limb in relation to the other parts, varies little from that when 
standing. 

The only injury with which it is likely to be confounded, is frac- 
ture of the neck of the femur within the capsular ligament; the 
diagnosis, however, is generally easy. In the fracture, the trochanter 
is drawn backward, and is less prominent than usual; the foot is 
everted, instead of inverted as in luxation; the limb can be readily 
restored to its proper length by extension, but immediately resumes 
its former position as soon as the extension is removed ; and finally, 
crepitation is produced by rotation. Moreover, the limb in fracture 



148 SYLLABUS. 

is susceptible of being moved about with much greater ease, though 
painful, than in dislocation. 

Fracture of the great trochanter, where it is detached and drawn 
up by the muscles. In this case, a prominence is felt above near 
where the head of the bone lies in dislocation, but every other symp- 
tom of the dislocation described is wanting. 

Manner of measuring the shortening by a tape extending from 
the spinous process of the ilium to the center of tuberosity of the 
condyle, etc. The degree of shortening varies much, from one and 
a half to three inches. 

The reduction of this dislocation is generally a matter of consider- 
able difficulty, and we are greatly indebted to Dr. Reid, of Rochester, 
for introducing a method much more simple than those which have 
been previously employed. 

The patient is best lying on the floor, and should be fully under 
chloroform. The surgeon, then grasping the knee with one hand, and 
the leg just above the ankle with the other, flexes the thigh upon the 
pelvis, and the leg on the thigh, carrying the limb across the sound 
one and the knee over the abdomen as high as the umbilicus. The 
knee is now turned outward on a line with the injured side, a pro- 
cedure which will draw the big toe from its inverted into an everted 
position, and of course incline the heel proportionably inward, or in 
the opposite direction. In the last stage, the foot is carried across 
the sound limb, and the knee pushed outward and downward, when 
the thigh being gently rotated, the head of the bone slips at once 
into its socket with an audible jerk, and the injured limb resumes its 
natural position. The whole operation may be performed in two 
minutes, or less. 

The whole procedure is a beautiful one, and is based on a thorough 
knowledge of the nature of the injury, and the anatomy of the parts, 
^he muscles which resist reduction are all relaxed in turn, and the 
head of the bone is made to enter the rent in the capsule through 
which it made its escape. Dr. Reid cannot be accorded too much 
praise for his discovery. 

Where the head of the bone is thrown into the sciatic notch, it 
rests on the pyriformis muscle, between the sacro-sciatic ligaments 
and the convex surface of the iliac bone. The capsular ligament is 
torn, and the psoas, iliac, and obturator muscles are put on the stretch, 
and occasionally more or less torn. 

The symptoms bear a close resemblance to those of the dislocation 



DISLOCATIONS. 149 

on dorsum of ilium, just described, and some writers regard them 
merely as modifications of the same lesion, the bone in one case being 
drawn, or thrown higher than in the other. The limb is shortened 
much less in this than the other, being only from half an inch to an 
inch, and is firmly fixed ; the great toe rests upon the ball of the 
sound one of the other foot; the knee is advanced in front of the 
opposite one, and turned in, but not so much as in the other luxation; 
the trochanter is lower than natural, and farther from the crest of 
ilium, and the head is so deep in the notch as to be rarely detected 
except in very thin subjects. Both thigh and leg are a little flexed. 

The dislocation into the thyroid foramen presents very different 
symptoms from the last two ; the head of the femur is thrown down- 
ward and forward into the foramen, resting on the external obtu- 
rator muscle, the great trochanter being turned backward toward the 
acetabulum. 

The symptoms are well characterized. The hip has lost its con- 
vexity, and there is a flattening where the trochanter should be, and 
sometimes even a depression ; the trochanter is removed beyond the 
natural distance from the anterior spinous process of ilium. The 
limb is increased in length, from one to two inches, and stands off 
in an awkward manner from the sound one, the knees being widely 
separated. The trunk is bent forward by the tension of the psoas 
and iliac muscles, and the head of the bone is distinctly felt in the 
thyroid foramen in thin subjects; the knee is advanced and everted. 
The motions of adduction, extension, and rotation cannot be execu- 
ted, but those of abduction and flexion may be by the surgeon, but 
not without pain. 

The diagnostic symptoms are the widely-separated state of the 
knees ; the elongation of the limb, which does not exist in any other 
luxation ; the forward inclination of the body ; flattened state of the 
nates ; the excessive tension of psoas and iliac muscles ; and impos- 
sibility of adducting, extending, and rotating the leg. The unnatu- 
rally low position of the trochanter is also an important sign. 

The pubic variety of dislocation is very rare ; the head of the femur 
is thrown on the horizontal branch of the pubis, above Poupart's 
ligament, and external to the femoral vessels, beneath the psoas, iliac, 
and rectus muscles. The limb is shortened about one inch ; the foot 
and knee are everted, and separated from their fellows ; the buttock 
is flattened ; the trochanter lies nearer the middle line than naturally, 
and the head of the bone is easily felt by rotating the limb ; adduc- 
tion and rotation inward are impracticable. 

11 



150 SYLLABUS. 

Reduction. — We have already described the mode of reduction 
applicable to most cases of the first variety spoken of, and there are 
many cases recorded of late in which the same manipulations have 
been successfully applied to the other forms of luxation. 

In the pubic and thyroid varieties, the surgeon may, in some re- 
cent cases, succeed by placing the heel in the perineum and making 
extension on the leg, and carrying the limb gradually across the 
sound one ; or, to increase the force, a long, stout noose may be 
attached to the thigh, above the knee, and passed around the opera- 
tor's neck. 

In robust, stout persons, or in chronic cases, it becomes necessary 
to resort to pulleys when the method by manipulation fails. 

Manner of using the pulleys described in each of the four dislo- 
cations, viz., the iliac, the sciatic, the thyroid, and pubic. 
After-treatment. 

Chronic Dislocations. — No definite time can be fixed for these 
cases. As a general rule it is not considered safe or proper to at- 
tempt reduction of these dislocations after six or eight weeks, and in 
many it is impossible much earlier. Where the head of the bone is 
lodged in the sciatic notch, or thyroid foramen, it becomes imbedded 
and firmly fixed in a comparatively short time, and the reduction 
much more difficult than in the other cases. 

The symptoms forbidding the attempt are immobility of the limb ; 
occlusion of the acetabulum by deposits ; and great derangement of 
the general health. With regard to the condition of the acetabulum, 
this is difficult to ascertain, and can only be inferred from the amount 
of inflammation following the accident. 



DISEASES AND INJURIES OF BONES, Etc. 

The bones have an organization resembling other tissues, and are 
subject to inflammation and its consequences, as well as specific dis- 
eases. From the amount of earthy matter that they contain, and the 
comparative deficiency of vascularity and sensibility, they resist dis- 
eases better, and the latter is much modified by the peculiar structure 
of the tissue. The progress of disease in bones and their appen- 
dages, from their organization, is necessarily very slow, as well as the 
process of recovery. A simple incised wound of the flesh will unite 
in two or three days, when the parts are brought in apposition, 



PERIOSTITIS. 151 

whereas a broken bone will require a month ; and the same tardiness 
is perceived in the development of suppuration in inflamed bones, 
and in the throwing off of sloughs, or necrosed portions of bone. 
The effects of simple inflammation in bones is bad enough, but the 
protracted and painful course of syphilitic, scrofulous, and other spe- 
cific inflammations in bone is well calculated to try human patience. 
Bones are the common seat of various tumors, simple or malignant. 

PERIOSTITIS. 

This is an inflammation of the periosteum or covering membrane 
of a bone. 

This affection is not uncommon, and may be produced by any of 
the causes which produce inflammation in other tissues, as cold, me- 
chanical injuries, syphilis, gout, scrofula, rheumatism, etc. It consti- 
tutes one of the forms of whitlow, and is likely to destroy the use of 
the finger. In deep-seated abscesses, where the pus comes in contact 
with bone, it very often inflames the periosteum. It may be acute 
or chronic, the latter being most common. 

Acute Periostitis. — In this form of disease of the fibrous covering 
of the bone you have all the ordinary signs of inflammation — heat, 
redness, swelling, and pain ; the part is more vascular, its color be- 
comes reddish or pinkish instead of white, it is tender to the touch, 
and the periosteum is thickened and softened ; its adhesion to the 
bone is less firm, sometimes to such a degree as to be easily peeled 
off, and the cellular tissue around is infiltrated with serum and lymph. 

Acute periostitis not unfrequently results in suppuration, particu- 
larly in the bones of the lower extremity, as well as in the fingers. 
Its progress in some cases is very rapid, as in whitlow. Mortifica- 
tion of the membrane sometimes occurs, and with it, usually, more or 
less necrosis of the bones, from their vascular connection. 

Symptoms of periostitis are violent pulsatile pain, with cedema- 
tous swelling, heat, and fever ; when pus forms there is an increase 
and softening of the swelling, pitting, glossy, erysipelatous appear- 
ance of the skin, with fluctuation. - 

When periostitis is the consequence of syphilis, the pains are always 
worse at night, particularly when the patient is warm in bed. The 
gouty and rheumatic forms must be made out from the history of the 
case, the symptoms not being in all cases distinguishable. One peculi- 
arity of these forms is the migratory character as to its seat, and the 
frequent involvement of joints. 



152 SYLLABUS. 

Treatment. — The first step is to ascertain the cause; to know 
whether the inflammation is simple, or specific. In the simple forms, 
whether traumatic or not, it is to be treated on the general principles 
of inflammation. 

In the specific forms, syphilitic, gouty, etc., the specific taint must 
be met by the appropriate remedies. 

The most important local remedies are leeches, iodine, blisters, 
saturnine, and cooling lotions, together with anodynes. Suppuration, 
from the density of the structure, is often difficult to detect, and when 
there is much tension, with severe pain, it is often proper to make 
free, deep incisions down to the bone ; this often gives great relief, 
and arrests destructive disease. 

Of internal remedies, iodide of potash in doses of five or ten grains, 
three times a day, affords most relief in the syphilitic form. In the 
gouty form, colchicum, purging, etc. are the remedies. 

Chronic periostitis is the most common form, and the membrane 
becomes greatly and extensively thickened from the deposition of 
lymph. Instead of being widely diffused, it is, in some cases, con- 
fined to detached points, appearing in little nodules. The enlarge- 
ment becomes very hard, not only cartilaginous, but often bony. 

The causes of the chronic are the same as the acute, and the symp- 
toms are also the same, but less violent. They are remarkably 
persistent, intractable, and require persevering treatment, usually 
with specific remedies. Iodide of potassium and mercury, Dono- 
van's solution, arsenic, blisters, iodine, etc. 

ENDOSTEITIS, OR OSTEOMYELITIS. 

Endosteitis, or osteomyelitis, is an inflammation of the endosteum, 
or medullary membrane. 

The causes of this disease are usually traumatic : fractures, gun- 
shot wounds, lodgment of foreign bodies in the substance of a bone, 
blows, the saw in amputations, etc.; cold is also a cause, as well as 
syphilis, gout, etc. 

Morbid Anatomy. — The appearances are much the same as the 
external periosteum: the membrane inflames, thickens, softens; the 
marrow is melted down, and suppuration occurs ; the external perios- 
teum opposite generally becomes involved, and the intervening bone 
is necrosed. 

The symptoms are difficult to diagnose in many cases, being like 



OSTEITIS. 153 

those attending inflammation of the bone and its fibrous envelope. 
In fact, it is only after an injury, amputation, etc., that we can, in 
most cases, make the disease out. When the end of the bone is ex- 
posed, and inflammation of the endosteum takes place, the symptoms 
may be watched and the diagnosis made. 

It is a very serious malady, involving the constitution deeply — not 
only giving intense local suffering, but resulting in phlebitis and 
pyemia, with all their terrible consequences. 

Treatment. — This is antiphlogistic. When the cavity of the bone 
is exposed, it may be washed out with astringents, etc.; when the 
cavity is not exposed, the pain and constitutional symptoms ex- 
cessive, and the disease suspected, we should cut down on the bone 
and make an opening with a trepan, to let the pus out and relieve 
the tension. 

OSTEITIS. 

Inflammation of the bone itself is not uncommon, particularly in 
young subjects, in whom the vascularity is great. It may be primi- 
tive, consecutive, acute or chronic, simple or specific. It may be 
limited to a small point of bone, or wide-spread. 

The spongy parts suffer much more frequently than the compact, 
and they ulcerate readily, while the latter are more liable to necrosis. 
The bones most likely to suffer are those least protected by soft 
parts, as tibia, ulna, clavicle, cranium, etc. It is very slow in its 
progress, although occasionally it travels with extreme rapidity, run- 
ning even to necrosis in a few days. 

Changes which take place in the bone as the disease advances. 

Terminations. — Osteitis may end in resolution, the parts gradually 
assuming their natural condition ; or the disease may cease, leaving 
the bone enlarged and hardened ; or it may pass to suppuration, 
ulceration, softening, or mortification, as seen in the soft parts. A 
bone rarely regains its natural size. 

Causes. 

Symptoms. — These greatly resemble periostitis, and it is often 
impossible to make a diagnosis ; but this is of no great practical 
importance, as the same treatment is applicable to both. 

Treatment must be conducted on general principles. 

Constitutional remedies. 

Local remedies. 

Suppuration and Abscess of Bone are common in all parts of 
bones, but when they occur on the surface, the connections of the parts 



154 SYLLABUS. 

are so intimate, and the symptoms of the two so alike, that we cannot 
determine whether it commenced in the bone or periosteum. Inflam- 
mation pervades every part of the substance of the bone, and suppu- 
ration may follow its march in every crevice. It occasionally happens 
that when a bone is sawn across, pus is seen oozing from every pore. 
When this occurs, the normal structure of the bone is more or less 
broken down and softened. In very rare examples, we see well- 
defined, circumscribed abscesses in the substance of bones. They are 
generally of very slow formation, and occur mostly in the spongy 
parts of bones, and particularly in the extremities of the tibia. 

The abscesses vary from the size of a pea to an egg, and contain 
very ill-conditioned, fetid pus. They may make their way into the 
joint, or be surrounded by a cyst, which gradually expands to con- 
siderable size as the pus accumulates. 

The symptoms of formation of pus here are much like those in the 
soft parts, except that the pain is much more excruciating and the 
influence on the constitution is much more violent. There are intense 
throbbing, lancinating pains, which are worse at night ; fevers of high 
grade, restlessness, emaciation, and frequent rigors. 

The only treatment that can give relief is the evacuation of the 
matter by the trephine. 

It is sometimes difficult to hit the exact spot, and it becomes neces- 
sary occasionally to apply the* trephine to several points. When 
successful, the operation gives immense relief, and the recovery is 
often rapid. 

CARIES, OR ULCERATION. 

This affection of bone is analogous, in every particular, to ulceration 
in the soft parts. Inflammation occurs, softening follows, with disin- 
tegration of the bony structure, and discharge of ill-conditioned pus. 
Caries differs from osteites in this — the latter is an inflammation of 
the bone, with inflammatory deposits, enlargement, etc., but without 
breaking down or softening of the structure, and formation of pus ; in 
caries suppuration, the bone is softened and broken down in structure. 

Caries attacks principally the spongy bones, as the vertebra, the 
innominata, carpal, and tarsal bones, etc.; while necrosis attacks the 
shafts of long bones and compact structures. 

Young persons, particularly children, are most subject to caries. 

Causes. — Caries almost invariably arises from some specific taint 
of scrofula or syphilis, particularly the former ; but mechanical injury, 
or any of the causes of inflammation already detailed, may rouse it 
into activity. 



NECROSIS. 155 

Morbid Anatomy. — The whole mass affected shows the marks of 
inflammation : it is softened, infiltrated with pus, and contains numer- 
ous little cavities, full of the debris of the bone ; it is soft, and can be 
cut with a knife. The surface often has a ragged, worm-eaten appear- 
ance, as in the cranial and other compact bones. 

Danger of joints being implicated. 

Symptoms. — In first stage, those of osteitis ; and the diagnosis can 
only be made after it has progressed to a certain point. 

Sinuses. 

Discharge. — Generally unhealthy and fetid. 

Constitutional disturbance. 

Prognosis. 

Treatment. — General ; local. 

Operations for relief. , 

Process of Reparation. — Granulation, etc. 

NECROSIS. 

By this term is meant the death of a part or the whole of a bone, 
and in reality is nothing more than mortification in the soft parts. 
Gangrene, mortification, are terms which have been applied to de- 
struction of vitality in a soft part, from inflammation or other causes, 
and they would apply just as well to the same condition in a bone. 
Custom, however, has decided differently. 

Most common in the long and compact bones. 

In the idiopathic form it is most common in strumous children, but 
not uncommon in adults, from traumatic causes. 

Causes — Are all those which have a tendency to produce inflam- 
matory affections, as well as those specific causes before alluded to, 
viz., cold and damp, foul, badly-ventilated apartments, mechanical 
injuries, scrofula, syphilis, gout, rheumatism, abuse of mercury, etc. 

Denudation of a bone in any way of its periosteum, by mechanical 
injury, exposure to unhealthy pus, etc., is a common cause of necrosis, 
though it does not invariably produce it. A bone may granulate 
healthily after this investment has been stripped off, and the injury 
inflicted be fully repaired without exfoliation. 

Extent of Necrosis. — It may be very extensive, or limited to a 
small spot; it may attack the external surface, the internal, or the 
whole thickness of a bone ; except in small Jbones, as those about the 
feet and hands, it is rare that an entire bone is necrosed. The entire 
lower jaw has been affected by it from the action of phosphorus, and 
in young subjects from that of mercury. 



156 SYLLABUS. 

The symptoms which usually precede necrosis are, up to a certain 
point, precisely those of osteites and abscess in bone. The soft parts 
around become involved in the inflammation and suppuration, and 
when the matter has formed in and around the bone, if not relieved 
by an opening, it soon or late works to the external surface, into a 
neighboring joint, or most convenient exit; not unfrequently the pus 
burrows to a considerable distance along the bone, and the abscesses 
thus formed among the soft parts are sometimes enormous. 

When the abscess is freely opened and discharged, the relief is 
great, and an opportunity is afforded, by aid of the probe or finger, to 
explore the parts fully and ascertain the nature and extent of the 
injury. If a part of the bone feels rough, we know at once it is dead. 
The process by which the "line of demarkation" is formed, and the 
dead bor>e is cast off from the sound, though very like the process by 
which sloughs are thrown off from soft parts, requires much greater 
length of time — not only weeks, but often months. The cause of this 
difference is explained by their comparative structure. 

Where the outer surface of a bone is affected and is cast off, it is 
called exfoliation. Where the whole thickness, to some extent, dies, 
it is called a sequestrum. An exfoliation is the casting off of the 
superficial lamellse of a compact bone, which becomes changed in 
color and consistence. A sequestrum may involve a part of a shaft, 
or the greater part, including one or both of the articular extremities. 
The dead portion is always rough, worm-eaten in appearance, or 
spiculated, of grayish, brownish, or, when exposed much to the air, 
blackish in color. 

Reproduction. — While the tedious process is going on by which 
the bony slough is detached, nature sets to work to repair the injury 
and provide a substitute for what is lost; the tissues around, and the 
detached periosteum, through the agency of their capillary circulation, 
throw out around the dying bone plasma, which is gradually organ- 
ized, and passes through the stages of fibro-cartilage, cartilage, and 
finally bone, the process occupying, according to age and other cir- 
cumstances, weeks or months. The new bone is at first a mere shell, 
encasing the old, but gradually becomes thickened to the extent of 
three to six lines, being almost or quite as strong as the original 
bone. The surface is very unlike, the latter being uneven and rough, 
and the whole formation is very hard, often having almost the density 
of ivory. In the long bones there is never a complete formation of 
the medullary canal, and the entire formation is unlike original bone, 
and has less capacity to resist disease or injury. 

The new bone is pierced at various points by openings of different 



OSTEOMALACIA — RACHITIS. 151 

sizes called cloacse, through which pus and fragments of the dead 
bone are discharged. These openings are probably attributable to 
deficiency of the periosteum, from which the bone is formed. Some- 
times these openings exist as long fissures. These openings discharge 
pus, and communicate with openings on the external surface, "It is 
an interesting fact, and one of no little practical value, that these 
openings are always situated in that portion of the new bone which 
is least covered by soft parts." 

Where the necrosed portion is simply a thin scale, the injury is 
repaired through granulations from the exposed surface of the sound 
bone. This is the case, whether the scale is from the external or 
internal surface. 

Symptoms of necrosis. 

Prognosis " 

Treatment " 

SOFTENING OF BONES, OR OSTEOMALACIA. 

This malady is often improperly confounded with rachitis, but dif- 
fers from it in being a disorder of adult life, and being always accom- 
panied by severe pain. Rickets, on the contrary, is peculiar to 
infancy, and free from local suffering. 

Extent of the disease. 

Morbid Anatomy. 

C?rj?es. 

Age and Sex. 

Symptoms. 

Diagnosis. 

Treatment. 

RACHITIS, OR RICKETS. 

This is an affection of the bones, characterized by a deficiency both 
of its earthy and organic elements, as is shown by the diminished 
quantity of carbonate and phosphate of lime, and the absence of 
chondrin and gelatin. 

Is a disease of infancy, occurring usually in the second year, and 
even earlier ; very rarely as late as the tenth or twelfth year. 

Causes. 

Morbid anatomy. 

Symptoms. 

Diagnosis. 

Prognosis. 

Treatment. 



158 SYLLABUS. 

Fragility of bones is rather an effect of disease than a disease. 

Causes. 

Symptoms. 

Treatment. 

TUMORS. 

The bones, like the soft parts, are subject to these affections, both 
in the simple and malignant forms. The former are : exostosis, fibro- 
cartilaginous growths, aneurism, hematoid formations, serous cysts, 
hydatids, and myeloid tumors. The latter, encephaloid, colloid, 
scirrhus, and melanosis. 

Exostosis may be regarded as a simple, local hypertrophy, the bony 
tumor or excrescence projecting from the sound bone, being similar 
to the latter in structure ; it is a bone drawing from a bone. 

Most common in young subjects. 

They vary in size from a shot up to enormous bulk. 

May occur on any bone, but most common in the superficial ones ; 
may be one or many. 

Shape. 

Causes. 

Structure. 

Progress. 

Diagnosis. 

Prognosis. 

Treatment. 

Fibro-cartilaginous tumors, or enchondroma, may be developed 
in the cancellated structure, or on the outer surface of bones, beneath 
the periosteum. Its figure is globular ; surface nodulated, consistence 
firm ; color white or grayish ; composed of fibrous and cartilaginous 
substance. 

It ordinarily affects one bone, is not malignant, and gives little in- 
convenience except from its size; peculiar to early life; slow in prog- 
ress, and may occur simultaneously on several points of the skeleton ; 
may occur anywhere, but most common in metacarpal bones, on the 
fingers, humerus, and lower jaw. It has been called osteosarcoma, 
a senseless term. When of long standing, often undergoes ossifica- 
tion. 

Remedy, excision. 

Aneurismal tumors of bone resemble aneurism by anastomosis in 
structure, being a development of small vessels. Its favorite seat is 
the head of the tibia, although it may occur elsewhere. Always 



FRACTURES. 159 

commences in the cancellated structure. After it has developed to a 
certain point, deep-seated pain and pulsation are felt, like in aneu- 
risms. Sometimes very large. 

Amputation is the only reliable remedy. 

Atrophy of bones. 

Hypertrophy of tumors. 

Sero-cystic tumors. 

Hydatic tumors. 

Malignant formations. 

Neuralgia of bones. 

FRACTURES. 

By the term fracture, is meant a sudden solution of continuity in a 
bone, produced by mechanical violence, or muscular contraction ; in 
plain English, a fractured bone is a broken bone. 

The subject of fractures is perhaps the most important that can 
engage the attention of the surgeon ; they are the most frequent of 
all important injuries, the least generally understood, and the most 
generally badly treated. The reputation of young surgeons suffers 
more frequently from malpractice in this department than any other. 

Fractures have been divided into simple, compound, and compli- 
cated. They are also divided into transverse, oblique, longitudinal, 
incomplete, and comminuted. 

The liability to fracture differs much with age, and other circum- 
stances ; in children, for example, where the animal matter predomi- 
nates, bones fracture with much difficulty ; while in old people, where 
earthy matter predominates, they break easily. 

The causes of fractures are generally divided into predisposing 
and exciting. 

The long bones, for obvious reasons, are more easily fractured than 
short ones; and where two long bones run parallel to each other, 
like the tibia and fibula, they rarely give way on the same level. 

There are many general considerations connected with the subject 
of fractures, but they may be more forcibly illustrated when we come 
to speak of individual fractures; there is one remark, however, that 
I would insist upon, namely, the importance of an early and thorough 
examination, with the view of establishing the diagnosis. If neces- 



160 SYLLABUS. 

sary, the surgeon may use anaesthetics to enable him to accomplish 
his object fully. It is also a fixed rule, that the sooner a fracture is 
dressed, the better. 

Repair of Bone. — When a bone is fractured, besides the solution 
of continuity in the bone itself, and consequent rupture of its blood- 
vessels, there is more or less injury of the surrounding soft parts, 
contusion, rupture of capillary vessels, etc. The first result of these 
injuries is an effusion of blood in and around the fractured extremi- 
ties of the bone, and the next is the development of inflammation in 
the injured tissues around, with considerable swelling, heat, and ten- 
derness. Yery soon the absorbents set to work to remove the effused 
blood, and as the absorption takes place, there is poured out in its 
stead a mass of plasma or lymph from all the injured and inflamed 
substances, namely, from the external and internal periosteum, the 
extremity of the bone, and the surrounding inflamed tissues. 

This substance is poured out in considerable quantity, resembling a 
pinkish jelly, and envelopes completely the extremities of the bones ; 
this is the first step toward the formation of bone, and reparation of 
injury. It becomes gradually more firm in consistence, passing 
through the stages of fibrin, fibro-cartilage, and cartilage, consuming 
from eighteen to twenty-five days, at which time the deposition of 
callus or bone commences. The delicacy and steadiness of this 
process shows the importance of setting broken bones as early as 
possible, and retaining them in perfect quietude. 

The process by which the osseous matter in the cartilage is depos- 
ited is identical with that by which the original bone is formed, and 
the bony matter is mainly, if not exclusively, deposited from the ves- 
sels of the periosteum. Dupuytren, by a series of well-conducted 
experiments on dogs, and other animals, established certain princi- 
ples in the reparation of bone, which were supposed to be equally 
applicable to man, and which have been received by the profession, 
generally, as established facts. In animals, the mass of plasma sur- 
rounding the extremities of the bones is transformed into callus, and 
the internal periosteum throws out a plug of callus which blocks up 
the cavities of the bones at their extremities, and passes through 
from one to the other, connecting them together when they are in 
direct apposition. This mass of external and internal callus was 
called, by Dupuytren, provisional callus, as it is intended to serve a 
temporary purpose. 

It is imperfectly organized bone, and there is a great excess of it 
around the extremities, forming frequently a considerable lump. A 



FRACTURES. 161 

new action is then set to work, by which the great mass of the exter- 
nal callus is removed, as well as the internal, thus opening the medul- 
lary canal again ; and the bony matter remaining, by which the frag- 
ments continue united, gradually assumes the structure of the original 
bone, and was denominated, by Dupuytren, definitive callus. This 
is the process which really takes place in animals, and has, until re- 
cently, been supposed to take place in man, occupying a space of 
several months for its completion. The recent experiments of Mr. 
Paget, and others, have clearly shown that this process is not appli- 
cable to man. In the latter there is no deposition of provisional 
callus, but, on the contrary, when the extremities of the bone are 
placed in apposition, there is a direct fusion by what Dupuytren calls 
definitive callus ; and even in these cases where the bones overlap, 
the deposition of callus takes place only from the surfaces in contact, 
the periosteum for a short distance around, and also the medullary 
membrane at the broken extremities. 

Where the bones are not in accurate apposition, and more particu- 
larly where they overlap to a greater or less extent, the deposition 
of bony matter is greater in proportion to the displacement of the 
bone, other things being equal. As the deposition of callus goes on, 
the medullary opening in the bones becomes closed, and the rough 
margins are gradually rounded off, and a perfect union takes place 
between the sides of the bones, giving them a regular, smooth, curved 
appearance. This process, for its entire completion, consumes months, 
and probably sometimes years. The work of nature is so perfect that 
even a medullary canal is often channeled through this unnatural con- 
nection. 

Treatment of Fractures. — The manner of transporting patients 
with fractured limbs. 

The importance of a good fracture-bed. 

The importance of dressing fractures as soon as convenient after 
the injury. 

Diastasis, or Separation of the Bones at their Epiphyses. — This 
is an accident that may occur up to adult age, or the period at which 
perfect ossification takes place, but is most common from the fifth to 
the fifteenth year. The symptoms of this lesion much resemble those 
of fracture, the principal difference being in the indistinctness of 
crepitation, and less liability to great displacement of the fragments. 
The prognosis is generally favorable, union taking place quite as 
promptly as in fracture. The treatment is also the same as in the 
latter accident. 



162 SYLLABUS. 

Ununited Fractures. — Fractures occasionally refuse to unite, in 
consequence of some deranged condition of the constitution, bad 
management on the part of the surgeon, or misconduct of the pa- 
tient. The process of union varies very much as to time, owing also 
to the condition of the system, or external causes. In some cases 
the bones do not unite at all, their extremities being rounded off, and 
smooth, like the surface of joints; in others the fragments are united 
by ligamentous or fibro-cartilaginous adhesions; in some instances an 
artificial joint is formed with a lining membrane and outer covering, 
resembling a synovial membrane and capsular ligament. 

Causes which prevent the union of bones. 

Treatment of ununited fractures. 

Vicious union of fractures. 

Symptoms and treatment. 

Diseases of the callus. 

Causes, symptoms, and treatment. 

Particular fractures. 

Fractures of the nasal bones. Symptoms and treatment. 

Fractures of the upper jaw and malar bone. 

Fractures of the Lower Jaw. — This bone may be fractured at its 
symphysis, or any point between this and its articulation ; most com- 
monly, however, the fracture takes place somewhere between the angle 
and the eye-tooth; it may be transverse, oblique, or longitudinal, 
single or multiple, simple or complicated. 

Occasionally there is a fracture on each side of the chin, so as to 
isolate it completely; sometimes a longitudinal fracture of the alve- 
olar process, detaching it, with the whole of the jaw-teeth, from the 
body of the bone. 

Causes of fracture. 

Symptoms. — Crepitation ; irregularity in the teeth ; displacement 
of the bone to the touch, at its lower margin, and where there is a 
double fracture ; drawing down of the chin by the muscles attached 
to the os hyoides. Fracture of the ramus or condyle may be detected 
by careful manipulation and eliciting crepitus, and the unnatural mo- 
bility of the bone at the fractured point. 

Treatment. — Simple fractures of this bone are usually easily man- 
aged, and union takes place in from four to five weeks ; the frag- 
ments are easily adjusted by passing the fingers along the base of the 



FRACTURES. 163 

jaw, bringing the teeth in their proper line, and placing them fairly 
in contact with those of the upper jaw, the mouth being firmly closed. 
If any teeth should be loosened, they should be retained by all means 
in their proper position, and allowed to adhere there. If necessary, 
loose teeth may be bound to neighboring sound ones by a silver wire, 
or other ligature. 

These cases are easily treated by the application of a piece of thick 
binders' board, sole leather, or felt, softened by water, and retained 
in position by a proper bandage, all of which will be demonstrated 
in my lecture. In complicated comminuted cases much difficulty fre- 
quently occurs in keeping the bones in proper apposition ; the sur- 
geon is here obliged to rely upon his own ingenuity to meet the diffi- 
culties. The mouth being necessarily firmly closed during the whole 
treatment, the patient must be nourished by fluid food, as broths, 
gruel, milk, etc., taken through a tube or from a spoon. 

Fracture of the hyoid bone. 

Symptoms; treatment. 

Fractures of the Clavicle. — For obvious reasons these are the 
most frequent in the human frame. They may be simple, compound, 
or comminuted ; unilateral or bilateral ; transverse or oblique. The 
fracture is almost always oblique ; the usual point of separation is 
at or near the middle of the bone where it is thinnest and weakest. 
Where the fracture is complete, the outer fragment being drawn 
downward, forward, and inward by the weight of the arm and 
shoulder; the inner fragment is slightly drawn up by the action of 
the mastoid muscle. Where the fracture is near either extremity, 
the displacement is comparatively slight, owing to the firm ligament- 
ous attachments of these portions. 

Causes, direct and indirect. 

Symptoms. — The shoulder drops below its natural level and turns 
forward and inward, the head and body incline toward the injured 
side, the arm cannot be rotated or hand carried to the face, and the 
patient instinctively supports the part by placing the opposite hand 
under the elbow, thus taking the Weight of the arm off from the in- 
jury. There is usually a marked angular deformity of the bones, 
whiclj is removed by thus pressing the arm up. Notwithstanding 
the variety of apparatus which has been contrived to overcome the 
difficulties, it is very rare to see a union of these bones without more 
or less deformity ; union, however, is perfectly solid, and the limb is 
as strong and useful as ever; it is only objectionable in females, 



164 SYLLABUS. 

where the part is exposed from their mode of dress ; but even here, 
unless the treatment is very bad, it soon ceases to be observable. In 
ordinary cases consolidation takes place in the adult in about five 
weeks, and in children in eighteen or twenty days. 

Reduction. — All that is generally necessary is to take hold of the 
elbow and to carry the arm upward, outward, and backward, a pro- 
cedure which rarely fails to effect approximation of the ends of the 
fragments. The object of treatment is, by some contrivance to re- 
tain the arm in the position it is placed after reduction. An infinite 
variety of apparatus has been contrived for this purpose, most of 
which are complicated and useless. I usually treat it simply with 
three pocket-handkerchiefs; the first is used as a sling, the center being 
placed under the elbow, and the extremities tied around the neck suf- 
ficiently tight to elevate the injured shoulder above the level of the 
opposite one ; this should be carefully watched and retained in this 
position, in order to make the humerus act more completely as a 
lever ; the elbow is brought as far forward as possible across the chest, 
and the hand carried up toward the opposite clavicle. The second 
handkerchief is used like the first, as a sling to support the hand ; and 
the third is tied across the elbow and around the chest for the pur- 
pose of confining the elbow firmly in this position. This simple 
apparatus answers all practical purposes. It is customary with most 
surgeons to apply a wedge-shaped pad in the axilla, extending down 
near the elbow, about two or two and a half inches thick at the upper 
extremity ; I have rarely found this necessary to keep the bones in 
apposition, and prefer to dispense with it where it can be done, as it 
is frequently uncomfortable from the pressure upon the large blood- 
vessels and nerves. This apparatus, like every other for fractured 
clavicle, should be applied next to the skin, and the dress arranged 
over it, as a fracture of this bone requires perfect quietude until the 
process of union is completed. 

Instead of the above apparatus, particularly in young subjects who 
are restless or unruly, long strips of adhesive plaster form an excel- 
lent substitute, and, in fact, may be considered, on account of its 
immobility, as the most perfect of all dressings. The adhesive plas- 
ter should be cut into strips about two inches in width, and suffi- 
ciently long to pass under the elbow and over the shoulders, and 
around the body in various directions ; so arranged as to confine the 
limb in the position above described. The great advantage of this 
dressing is, that it rarely requires readjusting before the union is 
complete ; all other apparatus, on the contrary, being made of yield- 
ing material, will stretch more or less, and require constant tightening 



FRACTURES. 165 

to keep the parts in position. Many other contrivances of good 
construction are in use, as those of Yelpeau, Fox, and Lewis, all of 
which will be described. 

Fractures of the Scapula. — Fractures of this bone are rare, but 
may occur in any part, from direct violence ; the body may be broken 
in various directions, the spine may be severed from the body, the 
neck may be fractured, or the coracoid process; but the most fre- 
quent point is the acromion process. 

The latter may be fractured in various ways, by direct or indirect 
violence. The symptoms are : the natural rotundity of the shoulder 
is destroyed ; the outer fragment is drawn down by the weight of the 
arm, which hangs motionless by the side of the body ; the head of 
the humerus can be felt in the axilla ; there is a depression at the 
situation of the fracture ; the distance between the shoulder and the 
top of the sternum is diminished, and a distinct crepitus may be 
detected on pushing up the arm in contact with the displaced frag- 
ment. 

The union is usually ligamentous, instead of osseous, owing to the 
difficulty of preserving the contact of the fragments. 

In the treatment of these cases, all that is necessary is to push the 
humerus up, place it in the same position as in fractured clavicle, and 
retain it there by appropriate apparatus ; the head of the humerus is 
thus made to act as a splint, retaining the acromion in its proper 
position. 

The fracture of the neck of the scapula is so exceedingly rare, 
that some good surgeons have doubted its possibility, unless from 
gunshot or penetrating wounds. 

The symptoms are: The acromion is unusually prominent; the 
head of the humerus is felt in the axilla ; the shoulder has a flattened 
appearance ; the limb is lengthened ; the coracoid process is thrown 
down below the clavicle, between the deltoid and pectoral muscles; 
severe pain and numbness are experienced in the axilla, and a dis- 
tinct crepitus is perceived on rotating the arm upon the scapula. 

Diagnosis. — A negligent surgeon might confound this with dislo- 
cation of the humerus ; but a comparison of the symptoms of these 
different affections will readily guard against error. The treatment 
is the ( same as for fracture of the clavicle; but it is a bad injury 
under any circumstances, and likely to be followed by stiffness, weak- 
ness, and paralysis of the limb. 

Fractures doubtless occur through the glenoid cavity, which are 

12 



166 SYLLABUS. 

difficult to diagnose, and which may explain some of the cases of 
anchylosis occasionally met with. 

Fracture of the coracoid process is of very rare occurrence, and 
is difficult to detect on account of the contusion and swelling 
which usually accompanies it ; the treatment is the same as for frac- 
tured clavicle. 

The fractures of the body of the scapula need not detain us, as 
their detection and treatment are matters of common sense. 

Fractures of the Ribs. — The central ribs, from their exposed and 
fixed position, are much more liable to fracture than the upper and 
lower ones, and more apt to break at or near the middle; these frac- 
tures may be simple, compound, or comminuted, and sometimes give 
a great deal of trouble by being complicated with wounds of the 
intercostal artery or lung. A fracture, instead of being at the point 
where the force is inflicted, may occur on the opposite side, from 
what is termed counter-stroke ; one rib or a half dozen may be 
broken at the same time ; the single fracture is usually a trifling 
injury, while a multiple one is very grave on account of the great 
violence which produces it. A fracture may usually be detected by 
placing the hand directly on the seat of pain and directing the 
patient to cough or take a long inspiration, when motion or crepita- 
tion will be felt. If this fails, the two hands should be placed flat 
upon the chest, one on either side of the suspected point, and first one 
and then the other pressed firmly against the ribs with a kneading 
motion ; the hands may be moved about to various points in this way, 
and crepitation will be almost certainly felt if fracture be present ; 
the patient is usually conscious of grating at the point of fracture, 
which is accompanied by a very sharp sticking pain, with inability to 
take a full inspiration. Where the lung is wounded by the points of 
the rib, there is generally spitting of blood, and occasionally emphy- 
sema. In the latter case, the air may fill the cavity of the .chest, 
causing a hollow sound on percussion, and total extinction of the 
respiratory murmur, attended with great increase of dyspnoea. When 
the air escapes from the chest it becomes diffused, through the cellular 
tissue, beneath the skin to a greater or less extent. The ribs being 
firmly united at their extremities to the spine and sternum, and lat- 
erally to each other through the intercostal muscles, they are not 
subject to overlapping or much angular derangement like other 
bones. Where the fracture is the result of great direct violence, 
one fractured extremity is sometimes depressed below the level of 
the other ; a simple uncomplicated fracture is rarely attended with 



FRACTURES. 167 

danger or difficulty. Where the pleura and lung are injured, the 
case is more serious. Emphysema in itself is not a symptom of much 
consequence. 

Treatment. — Fracture of the ribs without complication or dis- 
placement is best managed by encircling the chest with a broad 
bandage drawn sufficiently tight to compel the patient to perform 
respiration chiefly by the diaphragm, the intercostal muscles, thereby 
rendering the ribs perfectly passive. The bandage should be from 
eight to ten inches wide, and long enough to extend twice around 
the body. The ends being fastened by two pieces of tape, a shoulder 
strap is attached to prevent the cloth from slipping ; a common roller, 
properly applied, answers the purpose well, or, what is far better than 
anything else, strips of adhesive plaster three inches wide, and long 
enough to lap at the extremities; several of these should be applied 
very tightly after expiration, and arranged around the chest one above 
another ; these never slip or stretch, and may remain until the cure 
is complete. In females, a well-laced corset will answer every pur- 
pose, a triangular piece being cut out at the lower front part to allow 
due play to the diaphragm ; a compress over the point of fracture 
gives additional support. If the collection of air within the chest is 
such as to produce dangerous dyspnoea, it may be evacuated by a 
small trocar passed into the chest by a valvular opening between the 
ribs. Antiphlogistic remedies, local and general, as well as the free 
use of opiates, are in many cases indispensable. 

Fracture of the costal cartilages is a matter of extreme rarity. 
The symptoms and treatment of this injury are the same as for frac- 
ture of the ribs ; the union taking place by bony matter, and never 
cartilage. 

Fractures of the Sternum. — Fracture of this bone may take place 
in any part, is usually oblique, sometimes transverse, and in rare 
cases longitudinal. Generally in this fracture there is little or no 
displacement of the fragments, but, on the contrary, one is sometimes 
considerably depressed below the other ; like fracture of the rib, it is 
accompanied with great dyspcena, and commonly spitting of blood. 
Where there is displacement, the nature of the injury is evident at a 
glance ; where there is none, it may be detected by directing the 
patient to cough, while the hand is placed firmly along the sternum ; 
by pressing the sternum with the fingers at various points ; or by 
making the patient lie on his back, with a pillow beneath his shoulders. 

The displacement in most cases is easily corrected by making the 



168 SYLLABUS. 

patient sit up, placing the knee on the back between the shoulders, 
and drawing the latter back with the two hands. 

The prognosis of this injury, from the violence done, is usually 
unfavorable by its cause to the internal organs of the chest; where 
there are no complications, the recovery is not difficult. 

The treatment is by compress and bandage, upon the same princi- 
ple as fracture of ribs, together with proper constitutional remedies 
according to symptoms. 

Fractures of Vertebrae. — From their mode of articulation, strength 
of ligaments, and muscular coverings, fracture of these bones is 
extremely difficult. The causes are direct violence or contre-coups. 
Any portion of the body or processes of these bones may be broken, 
but an accurate diagnosis is impossible; the most important symp- 
toms are those dependent upon the particular point of the injury, 
from the intimate connection which exists between the vertebrae and 
spinal marrow. 

Difference of symptoms where the fracture is above or below the 
fourth cervical vertebra, implicating the spinal marrow. 

Fractures of the pelvic bones. 

Fracture of the Coccyx. — I have seen and recorded some curious 
facts in connection with the fracture and displacement of this bone, 
which will be explained in my lecture. 

Fractures of Superior Extremity. — The symptoms and treatment 
of fractures of the fingers and metacarpal bones are so obvious and 
so dependent on the general principles already laid down, that little 
need be said on the subject here. The whole hand usually requires 
to be splinted in these cases ; the fracture of a single finger cannot 
well be treated by applying a splint to it alone, but requires to be 
bound to one ur more fingers to secure sufficient quietude. 

Fractures of the Shafts of the Radius and Ulna. — Fractures of 
these bones may take place from direct or indirect violence, may 
occur at any point, but is most common in the inferior half, and the 
two bones rarely give way on the same level. The angular derange- 
ment, mobility, and crepitation usually declare the nature of the acci- 
dent at once ; all power over the forearm is lost, and there is acute 
pain at the seat of injury. The consolidation takes place in from 
thirty to thirty-five days, and the principal danger to be guarded 
against is the encroachment of the fragments on the interosseous 



FRACTURES. 169 

space, for, when union takes place under these circumstances, the 
rotation of the limb is greatly impeded. 

Treatment. — The usual mode of treatment, after making gentle 
extension and counter-extension and adjusting the fragments, is — 
first, to apply a bandage from the fingers to the elbow, the arm being 
bent at right angles ; next, two well-padded splints of binders' boards, 
thin wood, or other light material, and sufficiently long to extend 
from the extremity of the fingers to the elbow, are placed on the 
inside and outside of the arm, and firmly fixed in their positions by a 
roller from one extremity to the other, the thumb being kept up all 
the time ; the arm is then carried across the chest and suspended in 
a sling. 

I violate these received rules in two particulars : first, I apply no 
bandage to the arm itself; and second, I use shorter splints, the out- 
side one extending only to the carpus, and the inside extending only 
to the roots of the fingers, the hollow of the hand being well filled 
with cotton or some other soft material. 

My reasons for all this will be fully explained to you. 

Fractures of the Ulna. — Where the shaft of this bone alone is 
fractured, it is most common below the middle, and may be produced 
by direct or indirect violence. The fracture is detected by an irreg- 
ularity along the lower margin of the forearm, mobility, and crepita- 
tion on rotating the hand; the lower fragment alone is displaced, 
being drawn inward by the contraction of the pronator quadratus 
muscle. The danger in the treatment of this injury is, that the upper 
extremity of the lower fragment should remain in its unnatural posi- 
tion, be fixed there, and thus interfere with the rotation of the limb. 
This difficulty is best prevented by splints curved at the lower ex- 
tremity in a manner to incline and fix the hand in the opposite direc- 
tion or toward the radial margin. The head of the ulna is sometimes 
broken off alone, is easily detected, and treated by the method last 
mentioned. 

Fracture of the Olecranon.— This may be the effect of direct vio- 
lence or muscular contraction. 

The symptoms are: semiflexion of the limb, impossibility of ex- 
tending the forearm, a hollow at the ba*ck of the elbow, and a movable 
prominence above the elbow at a distance of one, two, or three inches. 
It is possible for a fracture of the extremities to take place above the 
expansion of the tendon of the triceps muscle, without displacement 
of the fragment. The union of this fracture is always by fibro-liga- 



1T0 SYLLABUS. 

raentous matter. The period required for the repair of the injury is 
from six to eight weeks. 

Treatment. — A splint well padded is applied on the front, extend- 
ing from the middle of the arm to the middle of the forearm, for the 
purpose of maintaining the limb in a straight position; a roller is 
then applied from the hand up to the neighborhood of the elbow, 
when the displaced fragment is pushed down to its natural position, 
and firmly fixed there by long strips of adhesive plaster; the bandage 
is then resumed, passed around and over the joint in the form of a 
figure of eight, and then carried on to the upper extremity of the 
splint, where it terminates. Passive motion must be resorted to in 
favorable cases at the end of about three weeks, to prevent anchy- 
losis. Where there is much contusion and inflammation of the part, 
antiphlogistics should be employed, and many days must pass before 
any tight bandaging can be used. 

Fractures of the Radius. — Fracture of the body of the radius may 
occur at any point, independently of the ulna, and is more common 
than the same injury of the ulna alone ; its most common seat is the 
inferior half of the bone, and its ordinary cause a fall upon the palm 
of the hand. 

The symptoms are well marked : deformity, mobility, crepitation, 
pain at the seat, inability to rotate the hand ; the ends of the frag- 
ments have a tendency to encroach on the interosseous space, and, if 
not watched, may lead to deformity. Either a false joint, or improper 
union in fractures, two or three inches above the wrist, are very apt 
to occur, and impair greatly the use of the limb. To prevent this 
deformity, two splints, shaped like the handle of a pistol in order to 
incline the hand to the ulna side, should be well applied, and I would 
strongly advise the omission of any bandage directly to the arm. 
Splints of this shape throw the upper extremity outward in its proper 
place, and consolidation takes place in about four weeks. 

This bone occasionally gives way at its superior extremity, de- 
taching its rounded head. 

The symptoms are : depression at the point of fracture, the bone 
being displaced forward and inward ; the best mode of detecting it is 
for the surgeon to grasp the hand, make extension, the elbow being 
grasped with the other hand, with the finger or thumb placed on the 
head of the radius ; the arm being then rotated, the head of the bone 
will remain stationary, while the radius moves, and crepitation may 
be felt. 



FRACTURES. 171 

Treatment, in every respect, the same as for fracture of both bones 
of the forearm, the splints being made to come well up to the joint. 

Fracture of the Inferior Extremity is one requiring particular 
study ; it is of frequent occurrence, is often mistaken for dislocation, 
and is prone to endanger the use of the hand. On the other hand, 
swellings from sprains of the wrist are often mistaken for fractures or 
dislocations. 

Causes. — Sponginess of bone, its articulation with the carpus, con- 
sequent connection with the hand, etc. 

This fracture is most common in middle-aged and elderly subjects. 
It may take place in every possible direction, from the joint to an 
inch and a half above, usually more or less oblique, frequently run- 
ning into the joint, and sometimes the extremity is divided into several 
fragments. 

The most conspicuous symptom of this fracture is the singular 
deformity of the hand, giving the limb the appearance of a disloca- 
tion of the wrist joint. This is owing to the fact that the lower frag- 
ment, along with the carpus, is drawn upward and backward, from 
an inch to an inch and a half above the, joints, by the action of the 
extensor muscles of the thumb, while the upper fragment forms a 
slight projection of the palmar aspect of the forearm. Immediately 
above the posterior prominence there is a depression. These symp- 
toms are effaced by extension and counter-extension, and return as 
soon as they are omitted. The lower end of the arm has a rounded 
form ; the hand is powerless and fixed ; crepitus may usually be de- 
tected just above the wrist joint. Instead of being thrown backward, 
the inferior fragment is sometimes forced in the opposite direction, 
forming a projection in the forearm, beneath the flexor tendons. 

Treatment. — The plan devised by Dr. Bond, of Philadelphia, is 
the one now generally employed, and meets the indications well. It 
consists of two splints, one of medium-sized binders' board, and the 
other of thin, light wood, furnished with a block and edges of thin 
sole-leather, about an inch in height, the whole presenting somewhat 
the appearance of a shallow trough. They are long enough to reach 
from a short distance below the elbow to within an inch of the 
knuckles of the metacarpal bones, the block of the latter resting in 
the 'hollow of the palm, and both being well padded with wadding. 
The splints are then placed in their proper position, and fastened in 
the usual manner. If one or more compresses are necessary to retain 
the fragments in position, they may be applied. 



112 SYLLABUS. 

Fractures of the Humerus. — These are frequent, and very im- 
portant. 

Shaft. — Fractures at this point are the simplest and easiest 
treated. 

Causes. 

Symptoms are plain, the deformity, preternatural mobility, and 
crepitus being well marked. There is generally some shortening. 
The direction of the displacement depends on the point of fracture ; 
if this is below the insertion of the deltoid, the inferior fragment will 
be drawn inward, but outward if it be above that point. 

Treatment. — One broad splint on the inside and the other on the 
outside, made of sole-leather or binders' board, and extending from 
the elbow to the axilla on the inside, and curved so as to suit the 
shape of the arm, makes a convenient form of dressing. A bandage 
should be first applied from the fingers to the elbow, and then con- 
tinued on to the shoulder, over the splints. If the bandage is coated 
from one extremity to the other with starch, it will retain its position 
much longer without derangement. Two curved tin splints, or four 
light wooden ones, may be made to answer well. I prefer, myself, 
two angular splints of binders' board, long enough to extend from 
the wrist to the axilla on the outside and inside. The forearm being 
thus motionless, there is less probability of derangement of the frag- 
ments. The hand should be placed in a sling, and the arm bound to 
the side. Consolidation occurs in a month. 

Inferior Extremity. — A small portion or the whole of either con- 
dyle may be broken off; and it not unfrequently happens that a trans- 
verse fracture of the humerus occurs just above them, thus dividing 
the bone into three fragments. These are among the most painful, 
difficult to diagnose and treat, of any in the whole skeleton. 

Symptoms. — When both condyles are severed just above the artic- 
ulation, the radius and ulna project backward, a hollow exists at the 
bend of the arm, the forearm is slightly flexed, and the distance 
between the elbow and wrist is sensibly diminished. When both 
condyles are fractured, together with transverse fracture of the hu- 
merus just above, in addition to the foregoing phenomena, there is an 
increased width of the bend of the arm and an appearance of greater 
flattening. The accident, whether accompanied by this occurrence 
or not, is liable to be mistaken for dislocation of the radius and ulna 
backward ; but the diagnosis may generally be readily determined by 
the fact that the symptoms which mark the former lesion promptly 
disappear on extending the limb, and that crepitus may be produced 



FRACTURES. 173 

when the forearm is rolled upon the humerus. When the inner con- 
dyle alone is detached, the ulna projects backward, but resumes its 
natural position on extending the limb; the condyle forms a tumor 
at the back part of the elbow; crepitus is discovered on bending the 
forearm ; and if the forearm be extended, the humerus will advance 
in front of the ulna as the latter recedes. 

A fracture of the external condyle is marked by the existence of a 
tumor at the outer and back part of the elbow, by crepitation on 
rotating the radius, by the supine position of the hand, by inability 
to move the joint, and by the constant semiflexion of the forearm. 

In all of these injuries there are great pain and rapid swelling, which 
obscure the diagnosis. The latter, however, should be clearly estab- 
lished, if possible, and the use of chloroform will facilitate us much. 
Leeches and antiphlogistic remedies are often necessary before dress- 
ings can be applied. 

The humerus is sometimes fractured transversely, but more fre- 
quently obliquely, when the symptoms similate very closely those of 
dislocation of the ulna and radius backward ; but gentle extension 
and counter-extension establish diagnosis. In children, a separation 
of the epiphysis may occur. In the hands of the best surgeons, 
all the fractures around this joint are troublesome, apt to result in 
anchylosis, and the use of the articulation is very slowly re-estab- 
lished. 

Treatment. — The propriety of placing the limb in a flexed position 
is now conceded, though some surgeons prefer to treat the injury with 
the arm extended; the principal reason for preferring the flexed posi- 
tion is, that the hand will be more useful if anchylosis should occur, 
if maintained at right angles, than when extended. Yarious angular 
splints, made of binders' board, tin, or wood, long enough to extend 
from the wrist to the axilla, have been recommended, placed either 
on the outside and inside or front and back of the arm. They should 
be well padded, and great care should be taken, by means of proper 
compresses, to guard the points of the condyles from pressure, which 
might result in ulceration. Angular wire-splints, where they can 
be obtained, from their lightness and coolness, are preferable to all 
others. 

Compound fractures of this joint are usually serious injuries, de- 
manding, for the most part, amputation. 

Superior Extremity. — This includes the head, together with the 
anatomical and surgical necks. By the former, we mean the narrow, 
constricted portion between the head and its tuberosities ; and by the 



174 SYLLABUS. 

latter, all that portion intervening between these prominences and 
the insertion of the broad dorsal muscle, its varying from an inch to 
an inch and a half. 

Fracture of the Head is extremely rare, difficult to diagnose, and 
can only be treated by perfect repose of the limb. 

Fracture of the Anatomical Keck occurs at all ages. This point, 
in children, being the line of the epiphysis, sometimes gives way, even 
up to adult age, when ossification proceeds tardily. 

Symptoms. — This accident is very apt to be confounded with 
others. The head of the bone can be felt in the glenoid cavity; 
there is a slight hollow below the acromion, the axis of the arm is 
directed toward the coracoid process, and the elbow is somewhat 
separated from the trunk. Crepitation is either very faint or entirely 
wanting. 

Fracture of the Surgical Keck. — This is also uncommon. 

The injury is always attended with marked displacement ; the supe- 
rior fragment, yielding to the action of the supra- and infra-spinatus 
muscles, is drawn outward, while the inferior is drawn inward by the 
pectoral and dorsal muscles. 

This accident is usually detected by grasping the point of injury 
with one hand, the elbow with the other, when both crepitation and 
unnatural mobility will be perceived on rotation. 

The treatment of injuries at the upper extremities must be con- 
ducted on the same principles as those below. Well padded, curved 
splint, or binders' board, tin, etc., extending well up into the axilla, 
and a corresponding one on the outside, should be applied. The 
arm must be bandaged from the fingers up to the elbow, and the 
roller continued on over the splints to their upper extremity. A 
coat of starch will be found useful in retaining everything in position. 
A sling .should support the hand, the elbow being left free, and the 
arm firmly bound to the side. 

Fractures of the inferior extremity. 

Fractures of the Foot. — Symptoms, treatment, etc. 

Fractures of the Tibia. — It may give way at any point, but most 
commonly below its middle. Fracture of the shaft is most frequently 
oblique. It is usually readily detected, there being more or less de- 
pression, and perceptible irregularity, on passing the fingers along 



FRACTURES. IT 5 

the spine of the bone; the displacement is not great: in most cases 
where the tibia alone is fractured, the fibula, acting as a splint, keeps 
it in place. Where it is very oblique, and the upper fragment sharp, 
the projection may be considerable. When simple, this fracture unites 
in from four to five weeks. 

Fracture of the internal malleolus is not uncommon, is more or 
less oblique, may vary in its direction, is often more or less commi- 
nuted, and more or less frequently accompanied by contusion, and 
followed by violent inflammation. It is often attended by frac- 
ture of the external malleolus or lower part of fibula. The diagnosis 
is easily recognized by the position of the foot, which is always turned 
upward and inward, as if partially dislocated; also, by crepitation 
and mobility of the fragment beneath the fingers. 

Treatment. — This injury is easily managed by two splints extend- 
ing from the foot to the knee, a little wider than the limb, with 
splint-cloth and proper pads ; more complicated apparatus has been 
contrived, but this answers every indication. 

Where the fracture is at the upper extremity of the tibia, whether 
involving the joint or not, it is best treated in a straight position by 
Liston's or Physick's modification of Desault's splints, which keep up 
the necessary extension and counter-extension, and give proper lat- 
eral support. 

These injuries in the neighborhood of, or involving the knee-joint, 
are tedious, troublesome, dangerous, and likely to be followed by 
anchylosis. The wire splints, from their coolness, and facility with 
which they permit cold applications, are particularly applicable to 
this, and all injuries in the neighborhood of joints. 

Fractures of the Fibula. — From its connection with the ankle- 
joint, fracture of this bone is common, and may occur at any point, 
but is most frequent in its inferior fifth. When these injuries occur 
in the shaft of the bone above they are easily detected, and require 
the same treatment as fracture of the tibia. 

Causes.— It is usually the result of violent abduction of the foot, 
which causes the bone to give way about an inch and a half above 
the ankle. It is not unfrequently the result of direct violence from 
blows, wheels, etc. The upper extremity of the inferior fragment is 
always thrust inward, while the superior fragment remains in situ. 

Symptoms. — Where the fracture is at the lower part of the fibula, 
there is a depression at the point of injury, with eversion of the foot. 
If there is fracture at the same time of the lower extremity of the 
tibia, the eversion and deformity are much greater. Upon taking 



176 SYLLABUS. 

hold of the foot it will be found very movable ; there will be crepi- 
tation ; the foot is easily brought into its natural position, but the 
deformity returns as soon as the hand is removed. 

These injuries are quickly followed by echymosis and swelling, 
which obscure the diagnosis. They can only be mistaken for a sprain, 
from which the distortion of the foot, mobility, and other symptoms 
already detailed, readily distinguish them. These cases are very 
tedious, requiring months for recovery when the joint is at all impli- 
cated, and often followed by more or less permanent stiffness. 

Treatment. — The principal indication is to place the foot in the 
opposite direction from its distortion, and maintain it there. This 
is met by Dupuytren's splint, extending from the knee to a few inches 
below the foot, placed along the inner side of the leg, and covered 
by a wedge-shaped pad, with the thick end extending to the level of 
the heel. The foot and leg being thus well bandaged to the splint, 
the deformity is corrected by the foot being firmly drawn in. 

Fractures of both the Tibia and Fibula. — These injuries are very 
common, important, and often badly treated; they occur most fre- 
quently below the middle, oftenest near the lower extremity, and 
rarely do both bones give way at the same level. The fracture is 
almost always oblique, the tibia giving way in a direction downward 
and outward. In consequence of this direction of the fracture, the 
upper fragment is usually displaced somewhat inward, the extremity 
being sharp and prominent, while the lower fragment is displaced 
outward toward the fibula. 

The sharp extremity of the lower end of the upper fragment of 
the tibia is often thrust through the integuments at the time of injury, 
thus making a compound fracture ; or it may work its way through 
by ulceration at a subsequent period. 

Symptoms are well marked. 

Prognosis, —In simple fractures a good cure may be secured in 
from four to five weeks. In the compound form months are often con- 
sumed, and not unfrequently they result in amputation, and sometimes 
in deformity. 

Treatment. — Simple fractures of both bones are easily managed 
by two splints extending from the knee to the sole of the foot, a 
splint-cloth, and proper padding, where there is no shortening of the 
limb, or by splints or binders' board supported by the starch bandage. 
An important point is to preserve the great toe erect, and on a line 
with the inner margin of the patella. Where there is overlapping of 
the bones, and tendency to shortening, means should be resorted to 



FRACTURES. 1*1*1 

to maintain extension and counter-extension. The long splints of 
Physick or Liston, already alluded to, answer the purpose well. The 
apparatus of Mclntyre, Nathan Smith, and many others, of compli- 
cated construction, have been resorted to, and are very useful. In- 
stead of the gaiter, handkerchiefs, and bandages, which produce chaf- 
ing and ulceration, long strips of adhesive plaster are now generally 
used for extending and counter-extending bands. 

Complicated Fractures of the Leg. — These cases are the result, 
always, of great violence, and the injury done to the parts is so. great 
that the first question often arising is, whether an attempt should be 
made to save the limb or not. Where the bone and soft parts are 
crushed by railroad car or other heavy weight, or where they are ex- 
tensively shattered and torn by gunshot, or other violence, and more 
particularly where the ankle-joint is seriously implicated, a surgeon 
should not hesitate, but resort to amputation at once. The injury to 
the soft parts, including, particularly, large blood-vessels and nerves 
which preside over nutrition of the part, are generally more import- 
ant than injury to the bone itself. When the bone is extensively 
shattered, and the circulation and sensibility of the parts below un- 
disturbed, the fragments should be removed, and a chance afforded 
for preserving the limb. Where an extremity of the bone projects 
through the skin, and cannot be otherwise reduced, the wound should 
be enlarged with a bistoury. The treatment of all these bad frac- 
tures is much better managed by swinging the limb. 

In all compound fractures, after the proper adjustment of the frag- 
ments, the wound should be dressed as other wounds, and the air 
carefully excluded. Where there is little tendency to shortening, 
compound fractures are exceedingly well treated by the common frac- 
ture-box, as it is termed, the limb being well imbedded in bran ; and 
this may be, if thought proper, suspended, as before suggested. 

Fractures of the patella. 
Symptoms and treatment. 

Fractures of the Femur. — Fracture may take place in any point 
of the shaft, or in any direction through the extremities. 

One of the most common seats of fracture is in the upper fourth 
of the shaft, and from two and a half to three and a half inches 
below the small trochanter. The line of fracture is almost always 



178 SYLLABUS. 

oblique, extending from behind forward, and from above downward, 
being frequently from an inch and a half to two inches in length. 

Symptoms. — These are generally very obvious; the limb is short- 
ened from two to four inches, and is distorted by external angular 
derangement, both fragments being directed outward, and the upper 
lying in front of the inferior one ; the extent to which the superior 
fragment is tilted forward has been much exaggerated by most writers, 
as it rarely reaches an angle of 45°. It is thrown forward by the 
action of the psoas and iliac muscles. 

Fracture at the Middle of the Shaft. — This fracture is not com- 
mon, and its direction is almost always oblique, extending downward 
and forward, and the upper fragment overlapping the lower. The 
limb is everted and shortened, and the symptoms altogether charac- 
teristic. 

Fracture of the Inferior Fourth of the Shaft. — This is a par- 
ticularly important injury, from its proximity to the knee-joint. The 
fracture is usually oblique, and its direction the same as those above 
described. There is considerable shortening of the limb, the point 
of the upper fragment being prominent in front, and that of the 
lower in the popliteal space, while the knee and foot are everted. 
Sometimes it is so low down that the point of the upper fragment 
may press upon the patella and displace it. 

Treatment. — This is usually conducted among surgeons of the 
present day by splinting the limb in a straight position, and main- 
taining extension and counter-extension. We have already spoken 
of the importance of a proper fracture-bed. The endless variety of 
apparatus which have been contrived proves the difficulty which at- 
tends the treatment of this injury ; and I do not hesitate to say that 
with the best apparatus, it is rare to see the cure of a fractured thigh 
without shortening from half an inch to an inch. 

In children these accidents are most conveniently and best treated 
by an external and internal splint of binders' board, firmly supported 
by a starched bandage ; the external one should extend as high as the 
crest of the ilium, and be supported by carrying the bandage around 
the pelvis ; the inner splint should extend well up to the perineum. I 
may here remark that the starch bandage forms the best dressing in 
children, for all fractures of the upper and lower extremities. 

In adults, the apparatus of Desault, modified by Physick, and that 
of Liston, are generally preferred. I agree with Dr. Gross, notwith- 
standing, that these are awkward and often unsatisfactory contriv- 



FRACTURES. IT 9 

ances. I show you one like that Dr. Gross is in the habit of using, 
which he calls a fracture-box. 

The surgeon cannot be too vigilant throughout the course of treat- 
ment ; the extending and counter-extending bands must be watched 
to prevent shortening; any projection of either fragment must be 
met by proper compresses ; chafing of the heel, and other parts, must 
be guarded against, as well as displacement of the foot outward or 
inward. 

Most surgeons recommend a bandage applied directly to the limb, 
from the foot upward over the thigh, for the purpose of controlling 
spasm of the muscles and swelling; but these indications are suf- 
ficiently met by the pressure of these splints, when properly applied, 
and I always omit it. A bandage, however well applied, in two or 
three days becomes either too loose or too tight, and the patient is 
much annoyed by its frequent readjustment. 

Mr. Erichsen, of London, one of our leading authorities, prefers 
the starch bandage in the treatment of these fractures in adults, as 
well as in children, and applies it in the manner before described. I 
myself should be afraid to trust it in adults, but it may be useful as 
a precautionary measure if applied when the patient is first allowed 
to get up on crutches. It often happens that the union at this period 
is not so solid as the surgeon supposes, and distortion may take place 
if not guarded against. 

The double inclined plane, by which fractures of the thigh are 
treated with the limb in a flexed position, is not now much employed ; 
but I prefer it myself, when properly managed, to every other method. 
The principles on which it acts are nowhere well described, and are 
understood by few. 

It is peculiarly applicable in fractures of either extremity, com- 
pound fractures, and in cases where both thighs are fractured. We 
might describe the apparatus of Dr. Nathan Smith, Mclntyre, and 
others. 

The period of consolidation varies according to age, treatment, 
and condition of constitution, etc. It takes place in children, under 
favorable circumstances, in from twenty-four to twenty-eight days ; 
in the active period of adult life, from thirty-five to forty days ; and 
still later in old persons. It is, however, most prudent for patients 
not ,to bear the full weight of the body on the limb for two or three 
weeks after he commences the use of crutches, as in some cases the 
callus unexpectedly yields and distortion follows. 



180 SYLLABUS. 

Fracture of the Inferior Extremity. — This is extremely rare ; is 
almost always the effect of direct violence; is accompanied with 
severe contusion, and often laceration, not unfrequently demanding 
amputation. The condyles, like those of the humerus, may be frac- 
tured in any direction ; they may be single, double, or comminuted. 

Symptoms. — Owing to the firm attachment of muscles and liga- 
ments around the head of the femur, as well as the swelling and ten- 
derness, the diagnosis is often difficult; but, by laying hold of the 
condyles with the two hands and passing them backward and forward, 
and also by pressing the patella firmly against the condyles, and by 
rotating the leg, diagnosis may usually be made out. 

Treatment. — It is necessary in the first place to combat the local 
inflammation for some days before any dressing can be applied. It 
may then be treated either by placing the limb in the extended or 
flexed position, and sustaining it by the apparatus already described. 

Fractures of the Superior Extremity of the Femur. — In this term 
we include the head, neck, and portion of the bone to which the two 
trochanters are attached. The neck is more liable to fracture in old 
persons, and particularly after the fiftieth year, than in the young. 
This liability arises from two circumstances : first, the increased brit- 
tleness of the bone with age ; second, the change of the direction of 
the neck in relation to the shaft, it being oblique in young subjects, 
varying not much from an angle of forty-five, while it approaches a 
right angle in the aged. 

From the great width of the pelvis and direction of the neck in 
females, they are more liable to fracture of the neck than the other 
sex. The student should study well the ligaments and muscles around 
this joint. 

It is important to recollect that when the head of the bone is 
broken off, bony union rarely takes place, from the fact that the neck 
has a very imperfect periosteum, and is covered by a synovial mem- 
brane. The periosteum is the principal source of callus, and the 
synovial fluid interferes with union. 

Fractures of the upper extremity are divided into those within 
the capsula termed intra-capsular, and those without termed extra- 
capsular. 

Fracture of the intra-capsular kind may occur at any point and 
in any direction; but generally it is met just below the head, or 
between the head and center of the neck. The line of fracture is 
sometimes partly within and partly without the capsule, forming an 
interesting variety in connection with the question of bony union. 



FRACTURES. 181 

The Cause of Intra-capsular Fracture. — Trivial accidents gener- 
ally produce it, such as a moderate blow or fall on the trochanter, a 
trip or false step in walking, sudden twitch, etc. 

The symptoms of intra-capsular fracture are — 1st. Shortening of 
the thigh. 2d. E version of the foot. 3d. Preternatural mobility. 
4th. Crepitation. 5th. Change of position in the great trochanter. 
6th. Pain at the site of injury. 7th. Peculiarity of patient's body in 
erect position. 

Shortening is well marked in the standing or lying position. It 
varies from half an inch to more, depending in most cases upon the 
injury done the capsule ; and increases from muscular contraction 
some hours or even days after the injury, amounting sometimes to 
two or even three inches. Sometimes no immediate shortening 
occurs, in consequence of the lower fragment catching against the 
upper one. Mobility is one of the most important symptoms : if 
the foot be seized and rotated, while the hand is placed upon the 
great trochanter, not only will great mobility be observed, but the 
trochanter will describe a smaller arc of a circle than when the neck 
is entire. Crepitation will also be felt, and if extension be made, 
the limb is easily restored to its natural length ; but the shortening 
returns as soon as the extension is relaxed. 

Anatomical and pathological characters. 

Mode of Repair of Intra-capsular Fractures. — The union is by 
fibro-ligamentous matter, and not by bone. In many cases even this 
union does not occur, the ends of the bone being rounded off as in 
artificial joint, and occasionally nearly the whole neck is removed by 
absorption. The reasons why bony union does not take place here, 
are the anatomical characters of the parts already alluded to, and 
the impossibility by any apparatus of retaining the fragments in 
quiet apposition. 

It cannot be asserted that intra-capsular fracture never unites by 
bony union, although it must be extremely rare ; but it is well ascer- 
tained that where the fracture is partly within and partly without, 
good bony union may occur. 

Treatment. — As before stated,, intra-capsular fracture is an injury 
peculiar to old people, and the line of treatment to be adopted must 
depend mainly on the condition of the general health and strength. 
Most subjects would not bear the position and confinement necessary 
in this protracted treatment, which consumes some two or three 
months. In such cases, all that should be attempted is to place the 
limb extended over a comfortable pillow or cushion, and keep the 
patient at rest for a couple of weeks. The patient should then be 

13 



182 SYLLABUS. 

allowed to get up upon crutches and take gentle exercise ; making 
up his mind to something like a false joint and weak limb for life. 
On the other hand, where the patient is robust and can stand the 
necessary confinement, some retentive apparatus should be applied, 
and the subject kept at rest the requisite time, for two reasons: 
1st. Where the fracture is intra-capsular, ligamentous union will 
take place, thus making a comparatively useful limb. 2d. It not 
being always possible to make an accurate diagnosis, the fracture 
may be partly within and partly without the capsule ; in this case 
perfect bony union may take place. Either the double-inclined 
plane, or the apparatus of Physick or Liston described, may be 
used, as good surgeons are divided as to the choice between the 
flexed or straight position. Treatment has to be persevered in for 
ten or fifteen weeks, and the patient carefully watched to guard 
against chafing, bed-sores, etc. 

Extra-capsular Fracture. — The extra-capsular fracture is situated 
at the base of the neck of the femur, extending from above down- 
ward, and from behind forward, in the direction of the intertrochan- 
teric line. As before stated, the upper portion of the line may extend 
inward into the capsule, infringing more or less upon the neck of the 
bone. This injury is often accompanied by fracture of one or both 
trochanters. 

Symptoms. — These resemble very closely those of the intra-cap- 
sular variety. There is shortening from one to two or three inches ; 
and a peculiarity is, it is as great directly after the accident as at 
any subsequent period. The knee and foot are greatly everted, and 
all muscular power over them lost. In some rare instances the foot is 
inverted, there is remarkable mobility of the limb, and the crepita- 
tion is also very distinct. On rotating the limb, while the hand is 
placed on the trochanter, the latter turns like the end of a stick j 
sometimes, however, the trochanter is broken off, when it remains 
stationary on rotation. 

Prognosis. — This is not favorable, there being at the same time 
much injury, generally of both the bone and surrounding parts ; more 
or less shortening is certain to occur, and life is often endangered. 

Treatment differs in nowise from that of the shaft of the bone. 

Impacted fractures of the neck of the femur. 

Symptoms and treatment. 



LESIONS OF THE SCALP. 183 

Fractures of the great trochanter. 
Symptoms. 

LESIONS OF THE SCALP. 

Wounds. — The only peculiarity about injuries of the scalp is their 
liability to erysipelas, and proneness to implicate the brain. These 
wounds require to be treated on^the same principles as similar injuries 
elsewhere. 

Tumors. — Sanguineous tumors, or collections of blood beneath the 
scalp, often occur from blows, and not unfrequently in infants, from 
contusion during parturition. The blood may be situated beneath 
the scalp, the occipito-frontalis, or pericranium. It varies much in 
quantity, color, and consistence, being fluid or coagulated. Where 
it is the result of a blow, it often presents to the finger the sensation 
of a depressed portion of bone with well-defined, hard edges ; in most 
cases, however, it forms a considerable tumor or prominence. These 
accumulations of blood generally disappear under the effects of sor- 
befacients, iodine, etc. In other cases they become encysted, remain- 
ing for an indefinite period ; in others inflame and suppurate. 

Sebaceous tumors are also very common on the scalp. 

Sanguineous tumors are not unfrequent. Fibrous, fatty, and most 
of the forms of tumor, simple and malignant, which attack other 
parts of the body, may also occur here, and require similar treatment. 

Concussion of the Brain. — This is an exceedingly important sub- 
ject, and has been a fruitful field of discussion. 

The pathology of this condition is very imperfectly understood: 
a patient receives a violent blow upon the head by a fall or other- 
wise ; its functions to a great extent are for a time annihilated ; in 
some cases even death ensues, and yet on post-mortem examina- 
tion no trace of lesion is found, and the pathologist is left to vague 
conjecture. This injury may be produced by indirect force commu- 
nicated through the spine, as when a patient falls from a height, 
alighting on his feet or nates. 

Concussion differs much in degree, and the symptoms differ cor- 
respondingly. For convenience, concussion has usually been divided 
by writers into three stages, viz., collapse, reaction, and inflammation. 

Symptoms. — These differ much in degree and duration. When 
slight, consciousness may be disturbed or annihilated for a few 
minutes; the patient is prostrated; pulse and respiration feeble; 
sensation obtuse ; reaction occurs in a few minutes, and all the symp- 



184 SYLLABUS. 

toms pass off, except, perhaps, a dull headache and lassitude, which 
may last some hours. In the severer grades of this affection, the 
symptoms are much more marked, and may continue from one to 
several hours. There is great muscular prostration; the pulse and 
respiration are almost imperceptible ; there is partial or entire insen- 
sibility; great pallor of the surface; nausea, with vomiting; pupil 
generally contracted, though not always, being sometimes natural or 
even dilated ; the senses all in abeyance. The sphincters are all re- 
laxed. In this state of collapse, the leading indication is to produce 
reaction by external and internal stimulants, fresh air, dashing the 
face with cold water, stimulating enemata, etc. While attempting 
to bring about reaction, the surgeon should bear in mind the fact 
that reaction is likely to be followed by inflammation, and he should 
be cautious to give no more stimulants than are absolutely necessary 
to start into action the depressed powers of life. The patient should 
be kept quiet for some time, and warned against dangers which may 
occur from the effects of the injury many days, or several weeks after. 

The inflammatory or febrile stage constitutes the concluding 
stage, which usually occurs four or five days after the accident; but 
may come on weeks or months afterward. The leading symptoms 
of this stage are high fever, with all its usual attendants, severe 
pain in the head, intolerance of light, injected eyes, vigilance, deli- 
rium, etc., often terminating in spasms, paralysis, and coma. 

Anatomical characters. 

Treatment. 

Compression of the Brain. — By this term we mean a displacement 
of a portion of the brain by mechanical pressure in any way, as that 
for example caused by a depressed portion of bone, effusion of blood 
upon the surface or within the substance of the brain. 

Symptoms. — These vary somewhat in proportion to the extent 
and suddenness with which the concussion is produced ; they are 
usually a very slow pulse, sometimes intermitting ; respiration slow 
and stertorous; pallid countenance; dilated pupil; great disturb- 
ance of all the senses ; paralysis of the half of the body opposite 
the injury, together with relaxation of the sphincters, and the draw- 
ing of the muscles of the face to one side. 

In some few cases the paralysis exists on the side with the injury, 
and the dilatation of the pupil is also inconstant — sometimes one 
being dilated, the other not; and in others one or both are con- 
tracted. 

Differential diagnosis of concussion and compression. 



FRACTURES OF THE SKULL. 185 

Treatment of compression must be regulated by the nature of the 
exciting cause. 

Compression from extravasation of blood; situations of the ex- 
travasated blood; manner in which compression from this cause 
comes on; its diagnosis and treatment. 

Depression of bone, unlike the last variety; the symptoms here 
come on immediately. 

Compression of the brain resemble closely in symptoms those of 
apoplexy. 

Treatment. 

Compression from the effusion of pus. 

Fractures of the Skull. 

These fractures, like those of other bones, may present every possi- 
ble variety, and are particularly grave, from the implication of the 
brain and its membranes. 

The causes are direct violence, or indirect, communicated through 
the spinal column. The degree of force requisite to fracture the 
skull varies much in different subjects, according to its thickness and 
brittleness, a very slight blow in some cases producing fracture and 
depression. The bone usually gives way at the point of the blow, 
but not unfrequently there is severe fracture of the base of the 
cranium from contre-coup. 

This subject is complicated and full of difficulties to the student. 
The following division will facilitate his studies: 1. Simple fracture 
of the skull, without depression. 2. Simple fracture, with depres- 
sion. 3. Simple fracture, with displacement, and compression of the 
brain. 4. Compound fracture. 5. Fracture of the base of the skull. 
6. Punctured fracture. T. Fracture of the external table alone. 
8. Fracture of the internal table alone. 

Simple Fracture, without Depression. — In this injury there is a 
simple fissure of more or less extensive fracture, without external 
wound or material injury of the soft parts. The symptoms in these 
cases are generally obscure, there being no displacement of the bone 
to mark the diagnosis, and the treatment is simple. 

Simple Fracture, with Depression of Bone. — The extent of the 
fracture in these cases, the bone being sometimes considerably shat- 
tered from the violence of the cause, is usually accompanied by 
symptoms of concussion ; the membranes of the brain are likely to be 
injured by spicula of bone, and severe inflammatory symptoms occur, 
while those of depression are absent. 



186 SYLLABUS. 

Treatment. — Much discussion has arisen on this point, as to 
whether the depressed bone shall be interfered with or not. The 
judicious surgeon must be guided by the circumstances of each par- 
ticular case. Where there is simply depression of a portion of bone, 
without urgent symptoms, it should not be interfered with. Where, 
on the contrary, there is considerable depression, with comminution 
and severe contusion of the soft parts, it is better at once to cut down 
upon the bone, remove the loose fragments, and elevate the depressed 
portion. 

Simple Fracture, with Depression and Symptoms of Compres- 
sion. — The symptoms in this case are the same as those already 
described as belonging to compression; and we may here remark 
that their violence is not always commensurate with the extent of 
the depression. 

Treatment. — Much discussion exists on this point also, some con- 
tending for the immediate necessity of elevating the bone, while 
others are opposed. Most surgeons are in favor of immediate tre- 
phining, in order to anticipate the long train of evils which often 
arise from this unnatural position of the bone. 

Compound Fracture is characterized by an open wound communi- 
cating with the fracture, and there may or may not be comminution, 
depression, or other complication. The clanger from this injury is 
threefold : from shock, from inflammation, and from fungus of the 
brain. Sometimes the membranes of the brain are ruptured, and a 
portion of the brain escapes. This is a very alarming, though not 
always a fatal symptom. 

Treatment. — There being already an open wound, any depressed 
portion of bone should be at once elevated, loose fragments removed, 
and the case treated on general principles already detailed. 

Fracture of the Base of the Skull. — These are always regarded 
as very grave cases, and are the result of great force applied to the 
vertex, or communicated through the spine. The symptoms are 
usually those both of compression and concussion, and the attention 
of the surgeon is often directed to the seat and nature of the injury 
by the discharge of blood or serosity from the ear, which takes place 
in those cases in which the fracture implicates the petrous portion of 
the temporal bone. 

Treatment. — There is no room for operative interference here by 
the surgeon, the seat of the injury being entirely beyond his reach ; 



FRACTURES OF THE SKULL. 187 

all that can be done is to treat the constitutional symptoms accord- 
ing to the principles already laid down. 

Punctured Fractures. — By these we mean injuries or wounds of 
the skull by small penetrating instruments, such as bayonets, dirks, 
nails, etc.; and, though small and apparently insignificant, must be 
regarded as among the most serious injuries of the skull which we 
have to treat. Their great danger arises from the thinness and brit- 
tleness of the internal table, it being splintered and driven in in a 
conical form, so as to inflict more or less injury upon the membranes, 
and perhaps the brain itself. 

They are not likely to produce symptoms of compression, but are 
almost always followed by violent inflammation. 

Their nature is easily recognized by the introduction of the finger 
or the probe. If the patient escapes the immediate dangers of inflam- 
matory action, he may be the victim, in after-times, of epilepsy, 
mental imbecility, etc. 

Treatment. — On this point the surgeon should be decided. Tre- 
phining is the only remedy, and, however mild the symptoms may be, 
should always be resorted to where the inner table is depressed. 

Fracture of the external table may take place alone, and is a com- 
paratively trifling injury. 

Fracture of the internal table alone may also occur, as proven by 
dissections, though the diagnosis is impossible. 

Depression without Fracture. — This can only happen in children 
before the process of ossification is complete, and while the bones 
preserve a certain degree of elasticity. Sometimes depression or 
flattening occurs to an alarming extent, without fracture, from falls 
or severe blows. 

Treatment. — All operative interference in such cases must be laid 
aside. Cool lotions and antiphlogistic remedies constitute the proper 
treatment, and the bone, from its natural elasticity and the pulsatory 
movement of the brain, generally resumes its natural position, and 
the patient does well. 

Apparent Depression. — It is very important for the young surgeon 
to be aware of the possibility of this deceptive symptom, which has 
led many astray. It is caused in the following manner : A patient 
receives a severe blow on the head, and a tumor immediately occurs 
from the effusion of blood; on pressing the fingers over the surface, 
the middle portion will communicate a soft, excavated feeling, with 



188 SYLLABUS. 

sharp defined circumference, as if the bone were actually depressed. 
This delusive appearance is caused by two circumstances : first, by 
the condensation of the tissues at the point of the blow ; and second, 
the effusion of lymph around the margin of this deadened portion. 

Operation of Trephining. — Circumstances requiring it, and me- 
thod of performing it. 

Wounds of the Brain and its Membranes. 
Causes, Symptoms, and Treatment. 

Fungus of the Brain. 

Causes, Symptoms, and Treatment. 



For reasons detailed in the Preface, I conclude my Syllabus here, 
hoping to complete it before another year terminates. There are 
some subjects, as the diseases of the Eye, the Ear, and Orthopedy, 
which must be regarded as specialties, and only to be touched in a 
general way, in a course like those of our colleges. The following 
subjects, however, will be lectured on in the college and hospitals, 
and as fully treated as time will permit, and will also be brought into 
the next edition of the Syllabus, viz. : — 

Injuries and Diseases of the Nose and its Cavities. 

" " Air-passages. 

" " Neck. 

" " Chest. 

" " Jaws, Teeth, and Gums. 

Mouth and Throat. 

" " Rectum. 

u " Urinary Organs. 

" " Abdominal Organs. 

" " Male Genital Organs. 

" " Female Genital Organs. 

Hernia. 
Amputations and Excisions. 



Jau. 23 1861. 



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